Forearm shaft fractures: clinical guidelines

List of Abbreviations

EFA – external fixation apparatus

AO – Association for Osteosynthesis

VTE – venous thromboembolism

RH – radial head

DKP – diaphysis of the forearm bones

RTA – road traffic accident

CT – computed tomography

HDL – high-density lipoproteins

LDL – low-density lipoproteins

PT – physical therapy

Ministry of Health of the Russian Federation – Ministry of Health of the Russian Federation

MRI – magnetic resonance imaging

LMWH – low molecular weight heparin from the heparin group (B01AB)

NSAIDs – non-steroidal anti-inflammatory and antirheumatic drugs

UFH – unfractionated heparin (sodium heparin**) from the heparin group (B01AB)

PPFA – proximal forearm bones

SWD – surgical wound debridement

SCT – spiral computed tomography

RF – risk factors

PRM – physical and rehabilitation medicine

FS – functional status

Surgical antibiotic prophylaxis

ЧЭНС – transcutaneous electrical nerve stimulation for peripheral nervous system disorders

LCP – locking compression plate

MIPO – minimally invasive plate osteosynthesis

ORIF – open reduction internal fixation

Terms and Definitions

Internal fixation device – an orthopedic implant implanted beneath the patient's skin that connects bone fragments in the treatment of fractures, deformities, or nonunions.

Bone fragment – a portion of bone separated as a result of trauma, surgery, or a destructive process.

External fixation device (EFD) – an orthopedic device comprising an implant (a transosseous or extracorporeal element protruding through the skin, reaching or embedded in the bone) and an external (non-implantable) frame that connects bone fragments via transosseous elements during the treatment of fractures, nonunions, or gradual segment lengthening (correction of deformity).

Load – mechanical force applied to a limb, bone, and fixation system during treatment, typically recurring with constant periodicity (cyclically).

Fixation – a state in which relative or complete immobilization of fragments is achieved.

Fixation stability – resistance of the system to external loads, allowing it to maintain the constancy of the mutual orientation of fragments and the optimal distance between them.

Absolute stability – absence of fragment micromotion under conditions of anatomical reduction and interfragmentary bone compression following their fixation

Relative stability – controlled micromotion in the fracture zone that does not prevent indirect bone healing with callus formation and is achieved by splinting the fracture zone with restoration of axis, segment length, and elimination of rotational displacement of fragments.

Migration of fixation elements – loss of the optimal position of fixation elements due to bone resorption around them, occurring when allowable cyclic loads or their number are exceeded, or due to errors in the surgical technique of implanting the element into the bone (within the context of this topic).

Fracture union – mutual connection of fragments by living bone tissue as a result of the successful completion of reparative regeneration.

Delayed union / Nonunion – changes in the reparative regeneration of bone tissue leading to a decrease in its rate, cessation, or formation of a callus insufficient to perform mechanical function.

Post-traumatic deformity – fracture union with a disturbance of spatial relationships between fragments, including axial and rotational ones.

Contracture – restriction of the range of motion in a joint.

1. Brief information on the disease or condition

1.1 Definition of the disease or condition

Forearm diaphyseal fractures (FDF) encompass isolated fractures of the upper, middle, and lower thirds of the diaphysis of the radius or ulna, fractures of the diaphyses of both forearm bones, as well as diaphyseal fractures of one bone with dislocation of the other (Monteggia and Galeazzi fracture-dislocations). These fractures represent a disruption of the structural integrity of the forearm bones in the diaphyseal region due to trauma. According to the number of fragments, forearm diaphyseal fractures are classified into simple and comminuted.

1.2 Etiology and pathogenesis of the disease or condition (group of diseases or conditions)

FDF occur as a result of a high-energy external traumatic agent. Depending on the injury mechanism, direct and indirect impacts are distinguished. In the direct trauma mechanism, the force is applied directly to the fracture site. The indirect trauma mechanism is characterized by the traumatic force being applied at a distance from the fracture site. Depending on the energy of the injury, high-energy and low-energy fractures are distinguished [1]. The former result from motor vehicle accidents, falls from height, railway accidents, and industrial injuries. They typically lead to a direct impact on the forearm in the diaphyseal region and are accompanied by significant damage to the surrounding soft tissues. Fractures resulting from high-energy trauma are transverse, multifragmentary, or segmental in nature. Low-energy fractures involve an indirect trauma mechanism and more commonly occur due to bending or rotational forces, resulting in spiral and comminuted fractures [1]. In elderly patients, forearm diaphyseal fractures frequently occur against the background of reduced bone mineral density [2].

1.3 Epidemiology of the Disease or Condition

Forearm bone fractures are among the most frequent localizations of limb bone injuries. According to various authors, among all skeletal injuries, forearm fractures account for 9.1% to 36.5%, with up to 86% occurring in young, working-age individuals. The treatment of patients with forearm fractures presents a significant challenge due to delicate biomechanical interactions, a vast number of injury variants—involving either bone in isolation or both bones, at the same or different levels, combined with dislocations in adjacent joints. Precise restoration of the anatomy and biomechanics of the forearm is an essential prerequisite for a good functional outcome, as failure to meet this requirement leads not only to impaired supination-pronation and a deficit in motor activity, but also to nonunion of the bones. According to scientific literature, over recent decades, the incidence of such injuries has increased, as has the proportion of surgical interventions for fractures of this localization [3, 4].

In children, forearm fractures account for 40% of fractures across all age groups [5]. Forearm fractures are more common between the ages of 4 and 14 years, when children gain greater independence and begin participating in recreational and sports activities [6]. Diaphyseal fractures are more prevalent among prepubertal children [7].

1.4 Features of Coding the Disease or Condition

S52.2 Fracture of shaft [diaphysis] of ulna

S52.20 Closed fracture of shaft [diaphysis] of ulna

S52.21 Open fracture of shaft [diaphysis] of ulna

S52.3 Fracture of shaft [diaphysis] of radius

S52.30 Closed fracture of shaft [diaphysis] of radius

S52.31 Open fracture of shaft [diaphysis] of radius

S52.4 Combined fracture of shafts of ulna and radius

S52.40 Closed combined fracture of shafts of ulna and radius

S52.41 Open combined fracture of shafts of ulna and radius

S52.7 Multiple fractures of forearm bones

S59.7 Multiple injuries of forearm

1.5 Classification of the disease or condition

Diaphyseal fractures are divided into simple, wedge-shaped, and multi-fragmentary (complex).

Simple fracture – a fracture with a single line where the contact area between fragments after reduction exceeds 90%. Simple fractures are subdivided into spiral, oblique, and transverse or near-transverse.

Wedge fracture – a fracture containing 3 or more fragments. Following reduction, the main fragments remain in contact with each other. The wedge may be intact or fragmented.

Multi-fragmentary (complex) fracture also contains 3 or more fragments, however, unlike a wedge-shaped fracture, after its reduction there will be no contact between the main fragments. The intermediate fragment of a complex fracture can be spiral, segmental, or irregular.

To accurately determine the anatomical location of a fracture, its center must be identified. For a simple fracture, the center is the midpoint of the oblique or spiral fracture line; for fractures with a wedge, it is the widest part of the wedge or the midpoint of the fragmented wedge after reduction; for complex fractures, the center is determined after reduction with restoration of bone length as the midpoint between the proximal and distal borders of the fracture.

Diagnosis coding begins by determining the anatomical location of the fracture: bone and segment.

According to the latest revision of the universal AO fracture classification, fractures of the radius and ulna are coded separately. All fractures of the forearm bone diaphysis correspond to codes 2R (radius) and 2U (ulna). Fractures of this location are divided into the following groups:

2R2A – simple fracture of the radial diaphysis;

2U2A – simple fracture of the ulnar diaphysis:

A1 – simple fracture, spiral;

A2 – simple fracture, oblique (> or = 30⁰);

A3 – simple fracture, transverse (<30⁰);

2R2B – wedge fracture of the radial diaphysis;

2U2B – wedge fracture of schistose ulnar diaphysis;

B2 – wedge fracture, bending wedge, intact;

B3 – wedge fracture, fragmented wedge;

2R2C – multi-fragmentary (complex) fracture of the radial diaphysis;

2U2C – multi-fragmentary (complex) fracture of the ulnar diaphysis;

C2 – multi-fragmentary fracture with an intact segmental fragment;

C3 – multi-fragmentary fracture, irregular [8].

For open fractures of the forearm bones, the classification of R.B. Gustilo, J.T. Anderson (1976) [9] as modified by R.B. Gustilo et al. (1984) [10] is used.

Type I – open fracture, wound mildly contaminated, wound size less than 1 cm.

Type II – open fracture, wound greater than 1 cm and less than 10 cm in length without extensive soft tissue damage, flaps, or skin avulsion.

Type IIIA: open fracture with soft tissue coverage of the bone fragments, no periosteal stripping despite extensive soft tissue damage or the presence of flaps, or resulting from high-energy trauma regardless of the wound size.

Type IIIB: open fracture with extensive soft tissue defect, periosteal stripping, and comminuted fracture pattern, frequently accompanied by significant wound contamination.

Type IIIC: open fracture complicated by major vascular injury requiring surgical reconstruction, regardless of the extent of soft tissue damage.

The structural features of pediatric bone tissue determine the occurrence of specific forms of fractures in children—incomplete fractures, which have specific therapeutic tactics. Incomplete fractures occur in the form of subperiosteal fractures, plastic deformation, and greenstick fractures [11].

Subperiosteal fractures are characterized by preservation of the periosteum around the entire circumference of the bone with damage to underlying structures. Plastic deformation of the bone occurs under load and is not accompanied by damage to the cortical layer. Greenstick fractures are characterized by an incomplete fracture of the cortical layer with angulation and rotation due to plastic deformation of the remaining intact cortical layer.

When all layers of the bone are damaged, a fracture similar to that described in adults occurs. However, these forms of fractures in children also have peculiarities. The periosteum can maintain its integrity even in the case of significant displacement. In some cases, this allows it to be used as a "hinge" during reduction. Complete fractures usually occur in older children [12].

1.6 Clinical presentation of the disease or condition

The clinical presentation of forearm bone shaft fractures is characterized by severe pain at the fracture site, tenderness on palpation and axial loading. If fragment displacement is present, shortening of the forearm, visible angular deformity at the fracture site, and abnormal mobility of bone fragments are determined.

If a forearm bone shaft fracture is suspected, all patients must be evacuated to a medical organization to verify the diagnosis.

Complaints: pain in the forearm area, abnormal mobility, deformity at the fracture site, pain in wound areas (in open fractures), tenderness with movements in the wrist and hand joints.

Anamnesis: history of trauma, the patient describes a characteristic injury mechanism. Most often, forearm bone fractures occur as a result of a direct blow in a road traffic accident, a fall from a height landing on the forearm area, or criminal acts. In high-energy trauma, attention must be paid to concomitant soft tissue injuries [13]. In addition, when collecting complaints and history, the localization of the patient's pain should be clarified, as forearm bone shaft fractures can be combined with dislocations in adjacent joints.

Objective: forearm edema, restriction of active and passive movements due to severe pain syndrome, visually determined forearm deformity at the fracture level, tenderness on palpation, bone fragment crepitus, abnormal forearm mobility. In fractures of a single forearm bone, soft tissue deformity and edema are less pronounced, and local tenderness is localized only to the injured bone. Given the high-energy nature of the injury, assessment of the vascular and neurological status of the distal upper extremity is mandatory when a forearm bone shaft fracture is suspected [14].

In children, one of the manifestations of forearm injury that first attracts parents' attention is impaired limb function. When examining children, one must keep in mind the possibility of simultaneous injury to both limbs, which most frequently occurs when children fall forward supporting themselves simultaneously on both hands [15].

In a child with a forearm injury, deformity and edema are primarily noted. Their severity is proportional to the severity of the injury. If no pronounced deformity or edema is detected upon examination, the examination tactics change. If there is pain in the diaphyseal part of the forearm, the entire limb from the clavicle to the hand must be clinically examined, as shoulder and elbow joint injuries can cause radiating pain. In diaphyseal forearm injuries, edema and hematoma may be absent even in the presence of a fracture with fragment displacement, as the diaphyseal zone of the forearm bones is covered by a significant muscle mass. In incomplete fractures, tenderness on palpation is minor, and deformity and limitation of forearm rotation may come to the forefront [16].

2. Diagnostics, medical indications and contraindications for diagnostic methods

Criteria for establishing the diagnosis/condition:

• anamnestic data: indication of a characteristic injury mechanism of the upper limb (fall, blow to the segment, road traffic accident, etc.)

• physical examination findings: impaired function of the injured segment, local swelling and tenderness in the trauma region (pain exacerbated by axial loading), presence of abnormal mobility and/or fragment crepitus

• instrumental examination data: radiographic signs of fracture based on radiography of the ulna and radius including adjacent joints in 2 projections. Additional CT may be performed as prescribed by the on-duty or attending trauma surgeon-orthopedist to clarify the nature of the fracture and determine the degree of fragment displacement, especially in fracture-dislocations and suspected intra-articular fracture components.

2.1 Complaints and Anamnesis

In most cases, patients present with the complaints described in section 1.6 "Clinical Presentation".

2.2 Physical Examination

Physical examination findings are described in Section 1.6 "Clinical Presentation"

• The assessment of the following parameters by an orthopedic trauma surgeon is recommended to be performed no later than 1 hour after admission to the hospital, with mandatory indication of the results in the medical documentation:

- assessment of somatic status;

- visual and palpation assessment of local status [4, 13].

LEL 5Grade of Recommendation C (Level of Evidence – 5).

- measurement of blood pressure on peripheral arteries;

- general thermometry;

- assessment of the risk of thromboembolic complications (Appendix G2) [17].

LEL 5Grade of Recommendation C (Level of Evidence – 5).

• When making a decision on surgical treatment of a forearm shaft fracture, it is recommended to collect anamnesis and perform a physical examination to identify risk factors and cardiovascular diseases [19, 20].

Level CLevel 5Level of recommendation evidence C (reliability level of evidence – 5).

Comment: Risk factors for cardiovascular disease include: arterial hypertension, smoking, dyslipidemia (elevated total cholesterol >4.9 mmol/L and/or LDL cholesterol >3 mmol/L and/or HDL cholesterol in men <1.0 mmol/L, in women – <1.2 mmol/L and/or triglycerides >1.7 mmol/L), diabetes mellitus, family history of premature cardiovascular disease (<55 years for men and <65 years for women) [1]. Established cardiovascular disease is understood as: ischemic heart disease, cerebrovascular disease, peripheral atherosclerosis, chronic heart failure, pulmonary hypertension, valvular heart disease, cardiomyopathies [20, 21].

• For all patients referred for planned surgical treatment of a forearm shaft fracture, it is recommended to assess the risk of perioperative cardiovascular complications taking into account the type of planned surgical treatment, regardless of the presence of concomitant pathology, for the purpose of complication prevention [19, 22].

GRL CLEL 4Recommendation Grade C (Level of Evidence – 4).

Comments: When surgical treatment is performed for emergency (<6 hours) and urgent (6–24 hours) indications, preoperative risk assessment is not performed.

Minor orthopedic procedures are associated with a low risk of cardiovascular complications (the 30-day risk of myocardial infarction or cardiovascular death after surgery is less than 1%). Major orthopedic procedures carry an intermediate (moderate) risk of cardiovascular complications (the 30-day risk of myocardial infarction or cardiovascular death after surgery is 1–5%) [23].

• To assess the risk of perioperative cardiovascular complications, it is recommended to use a specialized algorithm [Appendix G3] [22, 24].

GCR CLEL 5Grade of Recommendation C (Level of Evidence – 5).

• Elective surgical treatment of a distal forearm fracture is recommended without additional workup in patients assessed as having a low risk of cardiovascular complications. In patients with intermediate or high perioperative risk of cardiovascular complications, it is recommended to evaluate the patient's functional status to prevent potential complications [23, 25].

GPP CLOE 4Grade of Recommendation C (Level of Evidence – 4).

2.3 Laboratory Diagnostics

• All patients diagnosed with a forearm shaft fracture for whom surgical treatment is planned are recommended to undergo the following diagnostic laboratory tests:

- complete blood count;

- urinalysis;

- general clinical blood biochemistry analysis;

- determination of main blood groups by the ABO system and determination of the D antigen of the Rhesus system (Rh factor);

- coagulogram (screening hemostasis test) [30, 31].

Level of Evidence 5Grade of Recommendation C (Level of Evidence – 5).

• When deciding on surgical treatment for a distal forearm fracture, it is recommended to measure blood levels of N-terminal pro-B-type natriuretic peptide (NT-proBNP) in cases of intermediate or high cardiovascular risk and low functional status of the patient (see Appendix G3) [1, 8, 29, 30].

LEL 5Grade of Recommendation C (Level of Evidence – 5).

2.4 Instrumental Diagnostics

Comments: Radiography of the ulna and radius including both joints is necessary to diagnose a forearm shaft fracture, determine the fracture pattern and degree of fragment displacement, rule out injury at other levels, and diagnose fracture-dislocations. Once a forearm shaft fracture is confirmed by imaging, the issue of hospital admission is addressed. The patient should be admitted to the hospital if surgical treatment is planned. If conservative treatment is chosen, immobilization of the upper extremity may be performed. The method of initial immobilization will be described below in the section dedicated to conservative treatment.

Comments. Indications for surgical treatment in patients with forearm shaft fractures are divided into relative and absolute. Absolute indications include fractures with major vessel and nerve injury, open and gunshot fractures, fractures in polytrauma, ipsilateral humerus and forearm fractures, bilateral forearm fractures, fractures of one or both forearm bones with fragment displacement in adults, and fracture-dislocations. Relative indications include fractures of one or both forearm bones without displacement or with minimal displacement (angular <10º or rotational <10º). In certain clinical cases, so-called social factors must be taken into account, such as the patient's refusal of prolonged conservative treatment and the need to restore extremity function in a short timeframe [1, 13, 18].

If there are indications for surgery and the patient refuses inpatient treatment, the reason for refusal must be documented in the medical records with the signature of the patient or their legal guardians (in case of legally established incapacity of the patient).

In incomplete fractures in children, there is no displacement in width, but angular and in some cases rotational displacement occurs, which is difficult to assess on radiographs. In subperiosteal fractures, rotational displacement is absent or minimal. In greenstick fractures, slight angular displacement may be accompanied by rotational deformity. In plastic deformation, radiographs reveal a smooth bone bend without rotational deformity. In complete fractures, displacement in width is generally observed. Such fractures are characterized by significant instability, even when partial or complete end-to-end alignment of the fragments is maintained [16].

In isolated ulnar fractures, the relationships in the radiocapitellar and distal radioulnar joints must be evaluated without fail [19].

• Echocardiography may be considered before planned surgical treatment of a distal forearm fracture in patients with low functional status, elevated NT-proBNP levels, left ventricular systolic dysfunction, cardiomyopathies, valvular heart disease, newly detected heart murmurs, and suspected cardiovascular disease [24, 36, 37].

LEL 5Grade of Recommendation C (Level of Evidence – 5).

2.5 Other Procedures

- Initial neurosurgeon consultation (examination): in case of nerve injury or suspected nerve injury and concomitant head injury;

- Initial consultation (examination) by a general surgeon: in case of suspected or objectively diagnosed concomitant abdominal and/or chest trauma;

- Initial consultation (examination) by a pediatric surgeon: in case of suspected or objectively diagnosed combined abdominal and/or chest trauma;

- Initial consultation (examination) by a neurologist: in case of nerve injury or suspected nerve injury and concomitant traumatic brain injury;

- Initial cardiovascular surgeon consultation (examination): in case of concomitant vascular injury or suspected vascular injury;

- Initial consultation (examination) by a pediatrician: in the presence of comorbid pediatric conditions (based on the child's medical history);

- Initial consultation (examination) by a general practitioner: in the presence of concomitant medical conditions (according to history) [41, 48].

Level CLevel 5Level of recommendation evidence C (reliability level of evidence – 5).

• If acute or unstable clinical conditions are identified, it is recommended to postpone elective surgical treatment of the distal forearm fracture and transfer the patient to a regional vascular center or specialized cardiac department to improve cardiac status and stabilize the patient [24].

Level CLevel 5Level of recommendation evidence C (reliability level of evidence – 5).

3. Treatment, including drug and non-drug therapies, diet therapy, and pain management

3.1 Conservative treatment:

• For adult patients with forearm shaft fractures upon admission to the hospital, the following minimum scope of care in the admission ward is recommended to stabilize the general condition:

- ensuring thermal comfort for the patient;

- adequate pain management;

- immobilization of the injured upper extremity;

- correction of fluid and electrolyte imbalances [41, 48].

Level CLevel 5Level of recommendation evidence C (reliability level of evidence – 5).

- in fractures of the shaft of one or both forearm bones without displacement or with minimal bone fragment displacement;

- in elderly patients, in the presence of severe comorbid pathology and low quality-of-life expectations;

- in the presence of comorbid pathology that is a contraindication to elective surgical treatment;

- upon the patient's voluntary refusal of surgery [1, 13, 18].

Level CLevel 5Level of recommendation evidence C (reliability level of evidence – 5).

Comments:

Conservative treatment consists of immobilization from the proximal palmar crease to the upper third of the arm in a position midway between supination and pronation. When the fracture is located in the upper third of the shaft, fixation of the forearm in a position of moderate supination is possible [1, 4, 13, 14].

Immobilization of the injured upper extremity is performed using various types of fixing bandages (application of an immobilization bandage in bone fractures). The type of bandage used depends on the patient's individual characteristics and the attending physician's preference. A plaster cast splint (application of a plaster cast in bone fractures) is most commonly used. Bandages made of synthetic materials as well as various prefabricated rigid braces can be used. The duration of fixation is about 6 to 8 weeks. During conservative treatment, staged radiological examinations (radiography of the ulna and radius) must be performed to diagnose potential secondary fragment displacement, which is an indication for surgical treatment.

• In children, conservative treatment is recommended for forearm shaft fractures without displacement [122].

Level CLevel 5Level of recommendation evidence C (reliability level of evidence – 5).

Comments:

Conservative treatment involves limb immobilization with a plaster splint (applying a plaster cast for bone fractures) extending from the metacarpophalangeal joints to the upper third of the arm, with the forearm in a neutral position between supination and pronation. The duration of fixation is approximately 3–5 weeks, depending on the patient's age and the type of fracture. Radiological control (radiography of the ulna and radius) is performed at one week, 2 weeks, and, in case of negative dynamics, at 3 weeks. At 7–14 days post-reduction, an increase in angular and rotational deformity is frequently observed, requiring repeated reduction. During this period, the primary callus is plastic, which allows for the correction of minor (within 10–15°) deformities [16].

• In children, closed reduction (reduction of bone fragments in fractures) is recommended for closed fractures with angular displacement greater than 10º and a width displacement greater than 1/3 of the bone diameter [122].

Level CLevel 5Level of recommendation evidence C (reliability level of evidence – 5).

Comments:

For incomplete fractures (plastic deformation and greenstick fractures), closed reduction of bone fragments followed by plaster immobilization is indicated. For complete diaphyseal fractures of both forearm bones, treatment begins with an attempt at closed reduction of the bone fragments, performed under general and/or regional anesthesia. If fragment apposition is impossible and the control radiograph shows significant residual displacement, soft tissue interposition is most likely present. In such cases, one should proceed to open reduction [25]. In some cases, an attempt at closed reduction is justified only if one of the two forearm bones remains stable [26].

For fractures with combined displacement during closed reduction, displacements are corrected sequentially: first length, then width, and finally angle.

In children, residual deformity after a fracture is corrected over time as the bone grows through remodeling. Remodeling is influenced by four main factors: age, the healing potential of the specific physis, proximity to the joint, and axial alignment with the joint. In diaphyseal injuries of the forearm bones, the following displacements are acceptable: in children under 10 years of age – angular deformity of less than 15° and width displacement up to the full diameter of the bone. In children older than 10 years, an angular deformity of up to 10° and width displacement up to the full bone diameter are acceptable. In children under 10 years, minor rotational displacement up to 10⁰ is permitted [16, 27].

Perioperative pain management

• To ensure adequate pain relief in patients with distal forearm fractures, it is recommended to use multimodal analgesia, which may include nonsteroidal anti-inflammatory and antirheumatic drugs (NSAIDs), paracetamol** (in children older than 3 months), gabapentinoids, and immediate-release opioids, taking into account age restrictions in the instructions for medical use; if multimodal analgesia cannot be prescribed, monomodal analgesia should be used [42–44, 123].

Adults – Recommendation grade A (level of evidence – 2).

Children – Recommendation grade C (level of evidence – 5).

Comments: Multimodal analgesia (MMA) involves the use of multiple analgesics (opioid and non-opioid) with different mechanisms of action, along with non-pharmacological interventions aimed at targeting peripheral and/or central sites of the nervous system [45]. This combination allows for more effective pain management by enhancing the effects of various drugs, which in most cases leads to a reduced frequency of prescriptions and/or lower doses of opioid analgesics. Thus, MMA improves the risk profile of each drug while providing synergistic pain control through different classes of drugs. Postoperative MMA may include psychotherapy, physical therapy, NSAIDs, paracetamol**, gabapentinoids, regional anesthesia (single injection or peripheral nerve catheter placement), local injections, and opioids [43, 46].

In modern scientific literature, authors emphasize the use of the lowest effective doses of opioids for the shortest possible duration, without using extended-release opioids. In adult patients, a single intravenous administration of #dexamethasone** 1.25–20 mg prior to surgery (60 minutes before the incision) can be used as an adjuvant during MMA, providing significant pain reduction [42].

It must be remembered that the duration of parenteral administration of most NSAIDs (ketorolac**, ketoprofen**, diclofenac**) is limited to two days, which requires timely switching of the patient to oral administration, changing the drug, or coordinating further use with the medical commission. The specific choice of local anesthesia method and medicinal products is made by the attending physician individually in accordance with the patient's characteristics, local protocols, and the equipment of the medical organization.

When prescribing analgesic therapy to children, a single dose should be chosen taking into account the child's weight and age. Preference should be given to drugs with oral or rectal routes of administration, avoiding intramuscular injections.

Recommended analgesic drugs are listed in Appendices A3.1–A3.3.

Surgical antibiotic prophylaxis

• In the surgical treatment of patients with closed distal forearm fractures, it is recommended to perform surgical site infection (SSI) prophylaxis with a single preoperative dose of a systemic antibacterial drug, taking into account age restrictions in the instructions for medical use, in order to reduce the risk of infectious complications [47, 48].

GCR CLEL 5Grade of Recommendation C (Level of Evidence – 5).

Comments. In accordance with international clinical guidelines for the prevention of surgical site infections [47, 49], the goal of SSI prophylaxis is to achieve bactericidal concentrations of a systemic antibacterial drug in tissues exposed to microbial contamination during surgery to prevent surgical site infections. The necessity of SSI prophylaxis is determined by the surgical wound class of the upcoming procedure: prophylaxis is not required for "clean" surgical wounds not involving the placement of orthopedic implants and metal hardware. SSI prophylaxis should be performed for clean-contaminated and contaminated surgical wounds, as well as for "clean" surgical wounds involving the implantation of orthopedic implants and metal hardware. For infected ("dirty") wounds, SSI prophylaxis is not indicated; instead, antibiotic therapy is administered.

• In patients with distal forearm fractures, it is recommended to use 1st and 2nd generation cephalosporins (cefazolin**, cefuroxime**) as the primary drugs for surgical site prophylaxis in traumatology and orthopedics; as an alternative in case of intolerance to beta-lactam antibacterials (penicillins), glycopeptide antibiotics (vancomycin**) or lincosamides (#clindamycin**) should be used [47]. These medications must be used in accordance with the age restrictions specified in the instructions for medical use.

GCR CLEL 5Grade of Recommendation C (Level of Evidence – 5).

Comments. For patients with an unburdened allergic history and no significant risk factors for methicillin-resistant Staphylococcus carriage, first- and second-generation cephalosporins (cefazolin**, cefuroxime**) are used for SAP, administered intravenously between 30 and 60 minutes before skin incision. In case of intolerance to beta-lactam antibacterial drugs, a combination of vancomycin** with one of the fluoroquinolones (ATC J01MA) (ciprofloxacin**, #levofloxacin**), administered over at least 60 min with the start of intravenous infusion 2 hours before incision, or #clindamycin** should be prescribed. In case of significant risk factors for methicillin-resistant Staphylococcus (MRS) carriage, the SAP regimen should include systemic antibacterial drugs (ATC: J01) with anti-MRS activity (vancomycin**). In most cases, a single preoperative dose of a systemic antibacterial drug is sufficient for effective prophylaxis. For prolonged procedures (more than 3 h) or massive blood loss, an additional intraoperative dose of a systemic antibacterial drug (ATC: J01) should be administered (approximate timing of intraoperative administration is 2 half-lives after the preoperative dose). Administration of systemic antibacterial drugs (ATC: J01) after wound closure in the operating room is inappropriate even if drains are present.

Single doses of the main antibacterial drugs for SSI prophylaxis in traumatology and orthopedic surgeries in adults: cefazolin** 2 g (for patients weighing ≥120 kg – 3 g), cefuroxime** 1.5 g, #clindamycin** 900 mg, vancomycin** 15 mg/kg as a slow intravenous infusion, ciprofloxacin** 400 mg, #levofloxacin** 500 mg. Single doses for children should be calculated based on actual weight: cefazolin** 30 mg/kg, cefuroxime** 50 mg/kg, #clindamycin** 10 mg/kg, vancomycin** 15 mg/kg. The use of fluoroquinolones (ATC: J01MA) during the period of musculoskeletal system development is contraindicated due to the risk of arthropathy [124, 125].

Comments. In cases of open fractures, prophylactic administration of systemic antibacterial drugs is effective in preventing early infection; the drug should be administered as soon as possible after the injury. Cefazolin** is the drug of choice, but in patients with open high-energy fractures with bone displacement and segmental loss, major vascular injury, or heavily contaminated wounds, it is advisable to broaden the spectrum of systemic antibacterial drugs to cover gram-negative pathogens. In such cases, adding #gentamicin** (at a dose of 6 mg/kg once daily) to cefazolin** may be considered [51, 52]. An alternative to this combination is #ampicillin+[sulbactam]** (at a dose of 3.0 g every 8 hours for 3 days) [53], the latter being particularly relevant in cases of risk of clostridial infection. According to most researchers, in Gustilo-Anderson type III open fractures, antibiotic therapy should not be continued for more than 72 hours after soft tissue wound closure [54].

Thromboprophylaxis

• Routine venous thromboembolism (VTE) prophylaxis during upper extremity surgeries performed under local or regional anesthesia is not recommended [55–56].

GPP BLOE 3Grade of Recommendation B (Level of Evidence – 3).

• In cases where general anesthesia or tourniquet time exceeds 90 minutes during upper extremity interventions, as well as if the surgery may significantly impair the patient's motor activity or if there is a history of VTE episodes, it is recommended to consider perioperative VTE prophylaxis [57].

Level CLevel 5Level of recommendation evidence C (reliability level of evidence – 5).

Comments: Major and minor upper extremity surgeries are characterized by a low risk of VTE [55-57]. However, given the growing population of individuals with genetically determined thrombophilia (antithrombin III, protein C, or S deficiency, factor V Leiden mutation, prothrombin G20210A mutation, etc.), the widespread and often uncontrolled use of estrogens, population aging, and the rising incidence of diabetes and other metabolic disorders that increase VTE risk, pharmacological thromboprophylaxis may be appropriate in patients with additional VTE risk factors being treated for humeral and forearm fractures, as well as extensive soft tissue injuries of the upper extremities. The final decision is made by the attending physician, taking into account the extent of injury, the nature of the planned intervention, and the patient's additional VTE risk factors. Perioperative administration of LMWH to this category of patients may be prescribed according to the regimens and dosages given in Appendix A 3.3 for 7–10 days (until discharge from the hospital) or for several days until normal/expected motor activity is restored

Recommended medications and thromboprophylaxis regimens are provided in Appendix A3.4. The issues of VTE prophylaxis in traumatology and orthopedics patients are discussed in detail in the 2022 guidelines [58] and the 2023 Russian expert recommendations [59].

Features of thromboprophylaxis in pediatric patients

• It is recommended to assess bleeding and VTE risks in hospitalized patients older than 6 months within 24 hours of admission [60] and periodically during their hospital stay [61–63].

GCR BLEL 3Grade of Recommendation B (Level of Evidence – 3).

Comment. Validated VTE risk assessment scales have not been developed for pediatric patients, nor have bleeding risk assessment scales for those receiving antithrombotic therapy; therefore, when deciding on VTE prophylaxis, individual bleeding risk factors (Appendix A3.6), VTE risk factors (Appendix A3.7), and the risk-benefit ratio should be considered [64, 66].

For VTE prophylaxis in children, mechanical and pharmacological methods are used.

• In pediatric patients with a high risk of VTE, it is recommended to consider prescribing prophylactic doses of UFH or LMWH [68, 69].

GCP BLeE 3Level of recommendation confidence B (level of evidence reliability – 3).

Comment. LMWH is preferred for pediatric patients [68, 69], but currently in Russia the use of all LMWHs is contraindicated in children, so their prescription is only possible by decision of a medical commission (off-label use).

Blood-conserving technologies

Comments. Tranexamic acid** effectively reduces blood loss and leads to a smaller decrease in postoperative hemoglobin levels in patients undergoing surgery for proximal humeral fractures. This effect is observed both during fracture osteosynthesis and shoulder arthroplasty.

Comments. Systematic reviews and meta-analyses demonstrate that perioperative administration of intravenous iron preparations, in particular ferric carboxymaltose**, in traumatology and orthopedic patients, especially in the postoperative period, is an effective alternative to blood transfusion, as it reduces the proportion of patients who received a blood transfusion, decreases the volume of packed red blood cells transfused, and leads to a lower incidence of infectious complications without altering mortality rates [73, 74].

3.2 Surgical Treatment

The ulna and radius form the skeletal framework of the forearm. The ulna is straight, lies medially, and participates in the formation of the humeroulnar, proximal, and distal radioulnar joints. The radius, curved outward, forms the humeroradial joint with the capitulum of the humerus proximally, in addition to the aforementioned radioulnar joints, and articulates distally with the proximal row of carpal bones via the radiocarpal joint. The curved shape of the radius allows for rotational movements, during which the ulna acts as the axis of rotation.

The bones of the forearm are connected by the interosseous membrane and the ligaments of the proximal and distal radioulnar joints. These connective tissue structures can be damaged in complex forearm bone fractures, leading to instability and severe impairment of forearm function.

Thus, even a fracture of a single forearm bone with displacement disrupts the function of the entire segment. This explains the necessity of surgical treatment for virtually all forearm bone fractures with fragment displacement. Osteosynthesis should aim to achieve absolute stability at the fracture site, resulting in direct bone healing without callus formation. This is crucial, as callus following fracture union can restrict rotational movements and thereby impair the functional outcome of treatment. Bridging plates with screw fixation (non-absorbable sterile bone fracture fixation plate with screws***, non-absorbable non-sterile bone fracture fixation plate with screws***, non-absorbable sterile orthopedic bone screw***, non-absorbable non-sterile orthopedic bone screw***), intramedullary nails (radius intramedullary nail, ulna intramedullary nail, non-absorbable orthopedic bone nail***, non-absorbable sterile orthopedic bone screw***, non-absorbable non-sterile orthopedic bone screw***), or external fixation devices achieving relative stability are permissible in comminuted fractures, i.e., in cases where achieving absolute stability is not feasible due to the nature of the fracture [1, 13, 75].

In children, indications for surgical treatment include open complicated fractures, fractures accompanied by complete dislocation of fragments into the interosseous space, repeated fracture with displacement, repeated displacements when the correct position cannot be maintained after closed reduction, presence of two fractures along one bone, presence of circulatory disorders, tunnel syndrome, soft tissue interposition, combined injuries [26].

• In patients with a combination of a distal humeral fracture and soft tissue injuries, it is recommended to assess the soft tissue condition in order to determine further treatment tactics [1, 4, 13].

GCR CLOE 5Grade of Recommendation C (Level of Evidence – 5).

Comments: In the presence of open fractures, the choice of further tactics is determined in accordance with the recommendations for the management of patients with open distal humeral fractures.

In the presence of closed soft tissue injuries (contusions, abrasions, subcutaneous hemorrhages, hematomas, skin degloving, etc.), the choice of further treatment tactics, timing, and method of forearm bone osteosynthesis are determined by the severity of soft tissue damage and the patient's general condition [1, 4, 13].

3.2.1. Intramedullary osteosynthesis

Comments: When performing intramedullary osteosynthesis of the forearm bones, the following implants are used: radius intramedullary nail, ulna intramedullary nail, non-absorbable orthopedic bone nail***, non-absorbable sterile orthopedic bone screw***, non-absorbable non-sterile orthopedic bone screw***.

Intramedullary osteosynthesis is indicated for comminuted diaphyseal forearm bone fractures when open anatomical reduction of the fracture with interfragmentary compression and subsequent plate osteosynthesis is not feasible. It allows for the restoration of the axis and length of the injured bone, as well as the correction of rotational displacements at the fracture site without exposing the injury zone. To reduce the risk of complications, preoperative planning is essential to identify the specific fracture architectonics, measure the diameter and length of the intramedullary canal, select an implant of appropriate design, length, and diameter, and strictly adhere to the installation techniques recommended by the manufacturers. During osteosynthesis, one must strive to restore the anatomical curvature of the radius.

Intramedullary osteosynthesis of the ulna is performed using an antegrade technique. The intramedullary canal is opened in the region of the olecranon of the ulna at a point that is a continuation of the medullary canal. Intramedullary osteosynthesis of the radius is performed using a retrograde technique; the canal for nail insertion is opened between the extensor tendons near Lister's tubercle. Closed fracture reduction is preferable, but if technically unfeasible, open reduction with exposure of the fracture site must be performed. When using locked nails, special attention should be paid to the proximal locking of the radial nail to prevent iatrogenic damage to the deep branch of the radial nerve [75].

In cases of diaphyseal fractures of both forearm bones with a simple fracture of one bone and a comminuted fracture of the other, combined osteosynthesis may be performed, involving open reduction and plate osteosynthesis for the simple fracture, and closed reduction with intramedullary osteosynthesis for the comminuted fracture [79-80].

In children, closed reduction with elastic stable intramedullary nailing (flexible intramedullary nail) is the method of choice. If closed reduction is not possible, open reduction may be required. Intramedullary osteosynthesis is recommended for unstable fractures (fracture of both bones at the same level, oblique, comminuted, and segmental fractures) [81].

The advantages of intramedullary osteosynthesis include minimal invasiveness, a relatively lower incidence of re-fractures, and easier removal of hardware compared to plates [82].

3.2.2 Plate Osteosynthesis

Comments: When performing plate osteosynthesis of the forearm bones, the following implants are used: non-absorbable sterile bone fracture fixation plate with screws***, non-absorbable non-sterile bone fracture fixation plate with screws***, non-absorbable sterile orthopedic bone screw***, non-absorbable non-sterile orthopedic bone screw***.

Plate osteosynthesis with exposure of the fracture site is indicated for all types of diaphyseal fractures of the forearm bones. In simple fractures, interfragmentary compression must be achieved by inserting a lag screw or by eccentric screw insertion into the combination holes of the plate [1, 13, 18]. In cases of comminuted fractures, bridging plate osteosynthesis should be performed without screws in the fracture zone. In this case, the goal is to restore bone length and correct angular and rotational displacements. Bone grafting may be used in the presence of bone defects; however, the graft material must be placed away from the interosseous membrane to avoid stimulating heterotopic ossification [1, 13, 86].

Surgical access to the ulna is performed along the line connecting the olecranon and the ulnar styloid process. Access to the ulnar diaphysis is achieved between the flexor carpi ulnaris and extensor carpi ulnaris. The plate can be positioned on either the posterior or anterior surface of the ulna, depending on the fracture configuration.

Surgical approaches to the radius. The anterior approach (Henry approach) is performed with the upper extremity fully extended at the elbow and supinated. The skin incision is made from the level of the radial head to the radial styloid process. The fascia is incised distally between the brachioradialis and flexor carpi radialis, and proximally between the brachioradialis and pronator teres. Injury to the deep branch of the radial nerve and branches of the radial artery in the proximal part of the approach must be prevented.

The dorsolateral approach to the radius is performed along the line connecting the lateral epicondyle of the humerus and the radial styloid process. Access to the radius is established between the extensor carpi radialis brevis and the extensor digitorum. Injury to the deep branch of the radial nerve and the superficial branch of the radial nerve distally must be prevented.

Plates for osteosynthesis of both forearm bones should be placed in mutually perpendicular planes to reduce stress on the hardware during limb movements and to decrease the risk of peri-implant fractures. In fractures of both forearm bones, osteosynthesis is performed first on the bone with the simpler fracture. A simple fracture is easier to reduce, and its fixation restores the anatomical length of one of the forearm bones, which is subsequently used as a reference when fixing the second bone. If the fractures are equivalent in severity, osteosynthesis begins with the ulna. After stabilization of both fractures, the range of rotational motion must be checked.

When performing plate osteosynthesis for diaphyseal fractures of the forearm bones, the following rules should be observed: the distance between surgical approaches should not be less than 7 cm to prevent circulatory disorders in the soft tissue skin bridge between the two incisions; iatrogenic damage to the interosseous membrane should be avoided during osteosynthesis; periosteal stripping from bone fragments should be minimized; it is preferable to use low-contact dynamic compression plates (limited-contact plates) with or without angular stability and 3.5 mm screws; at least three bicortical screws should be inserted into each fragment; when closing postoperative wounds, the fascia should not be sutured to prevent compartment syndrome; in cases of pronounced tissue edema where wound edges cannot be approximated (which is rare), delayed primary closure or skin grafting should be performed after 48-72 hours [1, 13].

In children, plate osteosynthesis is used primarily in adolescents for unstable (comminuted) fractures. Plate osteosynthesis is also the preferred method for fractures at the junction of the middle and distal thirds of the radius, where intramedullary fixation fails to provide stability to the distal fragment [26].

Plate osteosynthesis in children increases the risk of re-fracture after hardware removal, adversely affects bone healing, and leads to significant skin scarring [83]. Fixation with a straight dynamic compression plate straightens the physiological bow of the radius, which may lead to restricted forearm rotation [84].

3.2.3 External Fixation Device

- open fractures with significant soft tissue damage and a high risk of infectious complications from plate or intramedullary osteosynthesis methods;

- extensive skin and soft tissue defects that cannot be eliminated in the early post-traumatic period;

- infection at the surgical site;

- extensive bone defects requiring reconstruction using bone-lengthening techniques [1, 8, 87, 88].

Level CLevel 5Level of recommendation evidence C (reliability level of evidence – 5).

Comments. When applying external fixation devices (EFDs) for forearm bone fractures, the following implants are used: Schanz pins, Steinmann pins, Kirschner wires (orthopedic bone wire***), and threaded or stopper pins (orthopedic bone wire***).

External fixation as a definitive method of osteosynthesis for diaphyseal forearm fractures is rarely used due to specific complications and limitations (pin-track infections, difficulties in rehabilitation, patient inconvenience). As a rule, external fixation is used as a temporary (provisional) method of osteosynthesis in open fractures and polytrauma. Subsequently, once wounds have healed and the patient's general condition has stabilized, conversion to internal fixation is performed [91].

When placing an external fixator, the topography of major vessels and nerves must be taken into account, and fixation elements (pins and/or wires) should be inserted with respect to their skin projections [1, 87, 88].

The external fixation method in children is used for open fractures with soft tissue defects and allows for the correction of bone fragment displacement through acute or gradual reduction [89].

3.2.4 Surgical treatment tactics for fracture-dislocations

Comments: A Monteggia fracture-dislocation is a fracture of the ulna combined with a dislocation of the radial head and damage to the proximal radioulnar joint. A characteristic feature of this injury is that reduction of the radial head dislocation usually occurs spontaneously after length restoration and osteosynthesis of the ulna. Persistence of the radial head dislocation or subluxation most often indicates inaccurate reduction of the ulnar fragments. If necessary, reconstruction of the annular ligament of the radius can be performed. In the postoperative period, early functional loading of the limb or short-term immobilization with a brace for no more than 3 weeks from the time of injury is indicated. A Galeazzi fracture-dislocation is a fracture of the radius combined with a dislocation of the ulnar head and damage to the distal radioulnar joint. As with the Monteggia fracture-dislocation, reduction of the ulnar head occurs spontaneously after osteosynthesis of the radius. If subluxation of the ulnar head persists despite correct reduction of the radial fragments, fixation of the distal radioulnar joint with Kirschner wires (orthopedic bone wire ***) for up to 3 weeks is possible [1, 13].

Treatment of acute Monteggia injuries in children consists of closed reduction followed by plaster immobilization. With the forearm in supination, the elbow is flexed while applying simultaneous traction along the axis of the forearm, and pressure is applied to the prominent radial head from front to back and from outside in. At the same time, reduction of the ulna is achieved. The arm is fixed with a circular plaster cast from the upper third of the arm to the metacarpophalangeal joints, with the elbow flexed at an angle of 60–70° for 4–5 weeks. If treatment is initiated within the first 2–3 weeks after injury, a positive outcome is achieved in the majority of cases. If conservative treatment fails, surgical treatment is indicated. Open reduction of the radial head is performed, along with osteosynthesis of the ulna (intramedullary or plate fixation) [19].

Galeazzi fracture-dislocations in children are rare. Reduction of the ulnar fracture is performed, which leads to reduction of the radial head and stabilization of the distal radioulnar joint. If instability of the distal radioulnar joint persists, bicortical fixation with a Kirschner wire (orthopedic bone wire *** must be performed [90].

3.3 Other Treatment

Comments:

Emergency tetanus immunoprophylaxis is carried out in the form of:

- passive immunization or seroprophylaxis with human antitetanus immunoglobulin** (HATI), and in its absence, tetanus antitoxin** (TAT);

- active-passive prophylaxis consisting of the simultaneous administration of human antitetanus immunoglobulin** (or TAT in its absence) and tetanus toxoid** (TT) into different anatomical sites;

- emergency revaccination with tetanus toxoid** (or reduced-antigen diphtheria-tetanus toxoid** — Td-adsorbed) to stimulate immunity in previously vaccinated individuals.

The algorithm for selecting prophylactic agents for emergency specific tetanus prophylaxis is provided in Appendix A3.5.

Comments: In accordance with World Health Organization recommendations, post-exposure rabies prophylaxis includes local wound treatment and a course of immunization using rabies immunoglobulin** and rabies vaccine**, in accordance with their instructions for use. Depending on the circumstances of contact with a rabies-suspect animal, either a combined course of immunization with rabies immunoglobulin** and rabies vaccine** or the rabies vaccine** alone is prescribed. A combined course of immunization with rabies immunoglobulin** and rabies vaccine** is prescribed in all cases where there is a risk of developing a disease with a short incubation period [92].

4. Medical Rehabilitation and Sanatorium-Resort Treatment

Comments: In the conservative treatment of diaphyseal forearm fractures, immobilization is carried out with a plaster cast for 4–6 weeks. The objectives of this period are to create conditions for the earliest possible fracture consolidation and to prevent stiffness of the elbow and wrist joints.

The rehabilitation program consists of active finger movements, gripping and squeezing objects with the fingers, reflex (ideomotor) movements for the elbow and wrist joints, assisted active movements for the shoulder joint, isometric contractions of the forearm and arm muscles alternating with general conditioning exercises using the healthy arm. Light housework is permitted.

In children, consolidation of diaphyseal forearm fractures occurs significantly slower than metaphyseal ones. In the conservative treatment of diaphyseal forearm fractures, immobilization is carried out for 3–8 weeks depending on the child's age and the characteristics of the injury [15].

Comments: after the removal of immobilization, the objectives of rehabilitation are to improve blood circulation in the limb, restore the tone and elasticity of the arm and forearm muscles, mobility in the elbow and wrist joints, self-care, and arm functionality [94].

During the first two weeks, the rehabilitation program includes: active movements of the fingers and shoulder joint, assisted self-help movements in the elbow and wrist joints, passive mechanotherapy, gentle passive soft tissue stretching (positional treatment), hydrokinetic therapy for joint injuries and diseases, superficial manual massage techniques for the arm and forearm muscles, and low-frequency pulsed electrostatic field therapy.

Two weeks after immobilization removal, during a follow-up appointment (examination, consultation) with a physical and rehabilitation medicine physician / exercise therapy physician, the issue of prescribing dynamic exercises with additional weight and resistance for the motor muscles of the elbow and wrist joints is revisited, along with biofeedback training based on dynamographic parameters (strength) and goniographic parameters (joint angle) following bone fracture, electrical muscle stimulation (EMS) for correcting elbow contractures (as indicated), manual therapy for bone system disorders to stretch and increase the elasticity of arm and forearm muscles, and training in daily living skills, self-care, and occupational therapy [95, 96].

Comments: after surgery, the arm is supported in a soft orthosis. From the first days after surgery, assisted movements in the joints of the operated limb, changes in elbow position, isometric contractions of the forearm and arm muscles, and active movements in the shoulder joint are permitted. From the 2nd–3rd day after surgery and thereafter, as the fracture heals and pain subsides, the range of motion in the joints is gradually increased and daily activities are expanded.

The objectives of the early postoperative period are the prevention of general postoperative complications. Prevention of local complications includes reducing soft tissue edema and creating optimal anatomical and physiological conditions for the healing of tissues traumatized during surgery. Local cryotherapy, barotherapy-limb pressotherapy, pneumatic compression, low-frequency pulsed electrostatic field therapy, and low-level laser skin irradiation are prescribed [100].

Comments: two weeks later, during a follow-up appointment (examination, consultation) with a physical and rehabilitation medicine physician / exercise therapy physician, the issue of prescribing dynamic exercises with additional weighting and resistance for the motor muscles of the elbow and wrist joints is addressed, along with biofeedback (BFG) training based on dynamographic parameters (strength) and goniographic parameters (joint angle) for bone fractures, electrical muscle stimulation (EMS) of muscles correcting contracture in the elbow joint as indicated, manual therapy for bone system disorders to stretch and increase the elasticity of shoulder and forearm muscles, training in daily living skills, self-care, and occupational therapy [95, 96].

5. Prevention and Dispensary Observation

Prevention of forearm bone shaft fractures consists in citizens observing social safety rules when performing household chores, being in vehicle traffic zones, walking on poor-quality surfaces, and during icy conditions.

A significant share of responsibility in fracture prevention also belongs to state structures, which are obliged to ensure safety to prevent road traffic injuries, as well as ensure compliance with safety regulations in industries with increased risk of trauma.

Comments. Upon discharge from the hospital, the patient must be referred to a trauma center or outpatient trauma department with an indication of the treatment performed and detailed recommendations for the continuation of treatment and rehabilitation. This ensures continuity between the inpatient and outpatient stages of treatment.

Follow-up examinations with X-rays of the ulna and radius and assessment of functional recovery dynamics are performed at 6 weeks post-surgery (assessment of fracture consolidation degree and readiness for full limb weight-bearing), 12 weeks post-surgery (assessment of fracture consolidation degree and limb weight-bearing capacity), 24 weeks post-surgery (assessment of consolidation and functional recovery dynamics), and 1 year post-surgery (assessment of the functional outcome of treatment and deciding on the need and timing for implant removal).

In children, following metal osteosynthesis (fixation with elastic nails, plate osteosynthesis), immobilization with a plaster splint is performed for up to two weeks; in children over 10 years of age, a sling bandage is used for 7-10 days [101]. If the course is favorable, metal implants should be removed after complete consolidation – approximately 5-6 months after surgery. Physical activity is restricted for up to six months from the moment of injury [102].

6. Organization of Medical Care

Clinical application of recommendations: Traumatology and Orthopedics, Anesthesiology and Intensive Care, Medical Rehabilitation, Health Organization and Public Health.

Purpose of the clinical guidelines: These clinical guidelines have been developed to improve the quality of medical care and standardize diagnostic and treatment algorithms for patients with forearm bone shaft fractures.

Indications for elective hospitalization: unsatisfactory result of conservative treatment – absence of signs of forearm bone shaft fracture consolidation after conservative treatment or osteosynthesis surgery at 2.5-3.5 months post-injury or post-surgery [1, 13, 18, 79].

Indications for emergency hospitalization:

Patients with suspected or confirmed forearm bone shaft fracture must be referred to a hospital to determine the need for emergency hospitalization. Indications for emergency hospitalization are:

- fracture of one or both forearm bones with fragment displacement;

- combination of fractures with peripheral nerve dysfunction;

- open forearm bone shaft fracture;

- gunshot fracture of the forearm bone shaft;

- forearm bone shaft fracture accompanied by damage to major blood vessels and nerves;

- forearm bone shaft fracture as part of polytrauma;

- ipsilateral fractures of the humeral shaft and forearm bones [1, 13, 18, 79].

Indications for emergency hospitalization in case of a forearm bone shaft fracture are established based on:

1) the presence of patient complaints characteristic of a forearm bone shaft fracture;

2) the presence of characteristic clinical signs of a forearm bone shaft fracture;

3) the presence of radiological signs of a forearm bone shaft fracture in the patient;

Indications for patient discharge from the hospital:

1. Internal fixation of the fracture with hardware or stabilization with an external fixation device has been performed, or adequate plaster immobilization has been achieved during conservative treatment.

2. The first stage of rehabilitation has been completed.

3. There is no acute infectious process.

4. Refusal by the patient or their guardians (in cases of legally established patient incompetence) to continue inpatient treatment (the reason for refusal must be documented in medical records with the personal signature of the patient or their guardians).

7. Additional Information

No additional information required

Criteria for Evaluating the Quality of Medical Care

References

Appendix A1. Working Group Composition

1. Belenky I.G., MD, DSc, Associate Professor, Saint Petersburg I.I. Janelidze Research Institute of Emergency Medicine, Saint Petersburg, member of ATOR

2. Geroeva I.B., MD, DSc, Professor, National Medical Research Center of Traumatology and Orthopedics named after N.N. Priorov of the Russian Ministry of Health, Moscow.

3. Zhuravlev S.A., orthopedic trauma surgeon, Priorov National Medical Research Center of Traumatology and Orthopedics of the Ministry of Health of Russia, Moscow, member of ATOR.

4. Kleimenova E.B., MD, DSc, Professor, National Medical Research Center of Traumatology and Orthopedics named after N.N. Priorov of the Russian Ministry of Health, Moscow.

5. Mayorov B.A., Ph.D. in Medicine, Janelidze St. Petersburg Research Institute of Emergency Medicine, Pavlov First St. Petersburg State Medical University, St. Petersburg, member of ATOR

6. Mamedov N.A., orthopedic trauma surgeon, Priorov National Medical Research Center of Traumatology and Orthopedics of the Ministry of Health of Russia, Moscow, member of ATOR.

7. Nazarenko A.G., MD, Professor of the RAS, Priorov National Medical Research Center of Traumatology and Orthopedics of the Ministry of Health of Russia, Moscow, Vice-President of ATOR.

8. Otdelenov V.A., PhD, National Medical Research Center of Traumatology and Orthopedics named after N.N. Priorov of the Russian Ministry of Health, Moscow.

9. Sergeev G.D., PhD, Saint Petersburg Dzhanelidze Research Institute of Emergency Medicine, St. Petersburg, member of ATOR

10. Trofimova S.I., PhD in Medicine, Turner National Medical Research Center for Children's Orthopedics and Trauma of the Ministry of Health of Russia, St. Petersburg

Conflict of interest.

The working group on drafting the clinical guidelines for the treatment of forearm bone shaft fractures has no conflict of interest.

Appendix A2. Methodology for Developing Clinical Guidelines

Target audience for these clinical guidelines:

1. Trauma and orthopedic surgeons

2. Surgeons

3. General practitioners (family physicians)

4. Medical rehabilitation physicians

5. Healthcare organization and public health specialists.

Stages of evaluating the levels of evidence and grades of recommendation:

1. Definition of search and selection criteria for publications on clinical trials (CT) regarding the efficacy and/or safety of the medical intervention described in the recommendation statement.

2. Systematic search and selection of CT publications in accordance with the previously defined criteria.

Systematic search and selection of clinical trial publications:

The evidence base for the recommendations consisted of publications retrieved via information retrieval in the following databases: Central Scientific Medical Library (CSML) "Russian Medicine", MEDLINE (US NLM), and COCHRANE Library; scientific electronic libraries eLibrary.ru and "CyberLeninka"; as well as on the Internet using Yandex, Google, and Google Scholar search engines, by reviewing leading specialized peer-reviewed domestic medical journals on the subject and treatment guidelines for fractures from the international Association for Osteosynthesis AO/ASIF.

Table 1. Scale for assessing levels of reliable evidence (LRE) for diagnostic methods (diagnostic interventions)

Table 2. Scale for assessing the levels of evidence (LE) for prevention, treatment, and rehabilitation methods (preventive, therapeutic, and rehabilitative interventions)

Table 3. Scale for grading grades of recommendation (GR) for prevention, diagnostic, treatment, and rehabilitation methods (preventive, diagnostic, therapeutic, and rehabilitative interventions)

Procedure for updating clinical guidelines.

The update mechanism for clinical guidelines provides for their systematic revision—at least once every three years, as well as upon the emergence of new evidence-based data regarding the diagnosis, treatment, prevention, and rehabilitation of specific conditions, or in the presence of justified additions/comments to previously approved clinical guidelines, but no more frequently than once every 6 months.

Appendix A3. Reference Materials

Appendix A3.1 Pain management recommendations for major musculoskeletal trauma (surgical fixation of long bone fractures or complex joint fractures, extensive soft tissue trauma, extensive surgery, etc.) in adults

The table presents analgesic medications and their dosing regimens in accordance with the Clinical Guideline for Pain Management in Acute Musculoskeletal Trauma [45].

Appendix A3.2 Pain management recommendations for non-surgical musculoskeletal trauma (closed fractures, superficial wounds, etc.) in adults

The table presents analgesic medications and their dosing regimens in accordance with the Clinical Guideline for Pain Management in Acute Musculoskeletal Trauma [45].

Appendix A3.3 Analgesic dosage regimen for children

¹ In children under 12 years of age, morphine** is preferred when opioid analgesics need to be prescribed, as the use of tramadol** is associated with a higher risk of adverse reactions [135, 136].

² Use in children is not recommended, as its metabolite accumulates in the body and provokes seizures upon repeated administration [137].

Appendix A3.4 Recommended dosing regimens of low molecular weight heparins for the prophylaxis of high-risk VTE in conservative treatment and orthopedic surgery in adult patients at high risk for VTE

It should be noted that spinal or epidural anesthesia can only be performed 12 hours after the administration of a low-molecular-weight heparin dose and no earlier than 4-6 hours after the administration of unfractionated heparin (meanwhile, APTT or ACT values must be within normal limits) [127, 128].

Appendix A3.5. Scheme for selecting prophylactic agents when performing emergency specific tetanus prophylaxis [126]

1 – Instead of 0.5 ml of TT (tetanus toxoid), Td (tetanus-diphtheria toxoid) can be used if diphtheria vaccination with this preparation is required. If the wound location permits, TT is preferably administered into the wound area via subcutaneous infiltration.

2 – Use one of the specified preparations: PSTI or AIT; for children, PSTI is preferred.

3 – For "infected" wounds, 0.5 ml of TT is administered if 5 or more years have passed since vaccination.

4 – A full course of immunization with adult TT consists of two vaccinations of 0.5 ml each at an interval of 30–40 days and revaccination after 6–12 months with the same dose. According to the accelerated schedule, a full course of immunization includes a single vaccination with a double dose of TT (1 ml) and revaccination after 6 months to 2 years with a dose of 0.5 ml of TT.

5 – Two vaccinations according to the standard immunization schedule (for adults and children) or one vaccination according to the accelerated immunization schedule for adults.

6 – For "infected" wounds, PSTI or AIT is administered.

7 – All individuals who received active-passive prophylaxis must be revaccinated with 0.5 ml of TT or 0.5 ml of Td to complete the immunization course after 6 months to 2 years.

8 – When performing active-passive prophylaxis in children, 0.5 ml of TT is administered. After normalization of the posttraumatic state, children should be vaccinated with DTP vaccine (INN: diphtheria, pertussis and tetanus vaccine**. ATC: bacterial and viral vaccines combined) or DT toxoid (INN: diphtheria-tetanus toxoid**. ATC: immune sera).

Appendix A3.6 Bleeding risk factors in children aged 6 months to 18 years

Notes:

1. If the patient meets at least one "NOT recommended" criterion, avoid pharmacoprophylaxis, as the risk outweighs the benefit.

2. If the patient has at least one relative contraindication criterion, consider withholding pharmacoprophylaxis.

3. Consider consultation with a hematologist if the patient is at high risk for VTE with a high bleeding risk [62].

4. Uncontrolled hypertension is defined as systolic or diastolic blood pressure above the 95th percentile for age, height, and sex [63].

5. Coagulopathy is defined as INR >1.5, aPTT >44 s, fibrinogen <100 mg/dL, or platelets <50,000/μL.

Appendix A3.7. VTE Risk Factors in Children Aged 6 Months to 18 Years

Notes:

− Reduced mobility is defined as a decrease in mobility compared to baseline level or inability to participate in physical therapy.

− Central venous access device is defined as a non-tunneled catheter, tunneled catheter, or central venous catheter.

− A major burn is defined as a burn involving more than 50% of the body surface area.

− Major surgical procedures include operations lasting longer than 45 minutes.

− Critically ill patients are defined as those admitted to an intensive care unit (requiring inotropic support or mechanical ventilation).

− Thrombophilic states include antithrombin deficiency, protein C or S deficiency, factor V Leiden, or prothrombin gene mutation.

− Active malignancy is defined as receiving chemotherapy/radiation therapy within the preceding 6 months.

− Active inflammatory disease includes Kawasaki disease, inflammatory bowel disease, systemic lupus erythematosus, or nephrotic syndrome.

− Estrogen therapy includes systemic hormonal contraceptives or estrogen replacement therapy within the past 2 weeks.

− Obesity is defined as a BMI above the 95th percentile for age.

Key:

Low VTE risk:

• No altered mobility and 0-1 risk factors

Moderate VTE risk:

• No mobility impairment and 2-3 risk factors

• Altered mobility and 0-1 other risk factors

High VTE risk:

• No mobility impairment and ≥4 risk factors

• Altered mobility and ≥2 other risk factors

Thromboprophylaxis recommendation

Appendix B. Physician Action Algorithms

Appendix B1. Physician action algorithm for the management of forearm diaphyseal fractures

Appendix B2. Physician action algorithm for assessing cardiovascular surgical risk

Notes and abbreviations:

CVRF – cardiovascular risk factors (hypertension, smoking, dyslipidemia (elevated total cholesterol >4.9 mmol/L and/or LDL cholesterol >3 mmol/L and/or HDL cholesterol <1.0 mmol/L in men, <1.2 mmol/L in women, and/or triglycerides >1.7 mmol/L), diabetes mellitus, family history of premature cardiovascular disease (<55 years for men and <65 years for women);

CVD – cardiovascular disease (coronary artery disease, cerebrovascular disease, peripheral artery disease, chronic heart failure, pulmonary hypertension, valvular heart disease, cardiomyopathies);

rRCRI – reconstructed RCRI index (See Appendix G3);

FS – functional status (the patient's ability to climb 2 flights of stairs independently without stopping before the injury).

* – regional vascular center or specialized cardiology department.

Appendix C. Patient Information

Forearm shaft fractures are severe injuries requiring specialized treatment in a traumatology department. Conservative treatment of such injuries is possible only for fractures without fragment displacement. This type of treatment involves prolonged immobilization with a plaster cast or its analogs. Its main disadvantage is the increased duration of treatment and the need for prolonged rehabilitation, as immobilization results in contracture of the elbow and wrist joints. Surgical treatment is indicated for all fractures with fragment displacement. Linear plates with 3.5 mm screws, intramedullary nails, and external fixation devices in various configurations can be used to treat forearm shaft fractures. Treatment can be single-stage (for isolated closed fractures and satisfactory soft tissue condition) or two-stage, where the fracture is first temporarily fixed with an external fixator followed by conversion to internal fixation (in multiple and polytrauma, severe open fractures, and significant soft tissue injury). For these fractures, one must strive for complete restoration of the injured bone anatomy; if this is impossible due to the nature of the fracture, the axis and segment length must be restored, and rotational displacement eliminated. For this purpose, it is usually necessary to open the fracture site and reduce the fragments under direct vision. In all cases, one must strive for stable osteosynthesis that does not require additional external immobilization after surgery. This makes it possible to begin early rehabilitative treatment.

Rehabilitation treatment should begin immediately after surgery. It consists of passive and active movements in the joints of the upper extremity, physiotherapeutic procedures, and exercises aimed at normalizing the trophic supply of the damaged soft tissues and bone.

In cases of fracture-dislocations, active movements in the elbow and wrist joints may be restricted for up to 3 weeks after surgery, depending on the clinical situation.

During conservative treatment in the immobilization period, active movements in the hand and shoulder joints are necessary. Active movements in the elbow and wrist joints should begin immediately after removal of immobilization upon the presence of radiological signs of fracture union.

Appendix G. Assessment Scales, Questionnaires, and Other Evaluation Tools

Appendix G1. QuickDASH upper extremity disability questionnaire

Russian title: The shortened disabilities of the arm, shoulder and hand questionnaire.

Original title: The shortened disabilities of the arm, shoulder and hand questionnaire (Quick DASH)

Source: Quick DASH Outcome Measures: Russian translation. Institute for Work & Health, 2006. https: //dash.iwh.on.ca /available-translations

Type: questionnaire

Purpose: assessment of the impact of musculoskeletal injuries and diseases on upper extremity function.

Content:

INSTRUCTIONS: This questionnaire asks about your symptoms as well as your ability to perform certain activities. Please answer each question based on your condition over the past week by circling the appropriate number. If you did not have the opportunity to perform a specific activity last week, please choose the most appropriate response. It does not matter which hand you use to perform the action; please answer based on your ability, regardless of how you independently perform the task.

OPTIONAL MODULE SCALING. All 4 questions must be answered. Simply add the assigned values for each response and divide by 4 (number of items); subtract 1 and multiply by 25.

Notes and Comments:

To assess treatment outcomes in patients with fractures at the shoulder girdle and arm level, questionnaires have been developed to evaluate the functional result of treatment.

1) Disabilities of the Arm, Shoulder, and Hand questionnaire (Disabilities of the Arm, Shoulder, and Hand, DASH) was developed jointly by the American Academy of Orthopaedic Surgeons, the Council of Musculoskeletal Specialty Societies, and the Institute for Work and Health (Canada). It belongs to patient-reported outcome measures and was introduced in 1996 for the standardized assessment of the impact of various musculoskeletal injuries and diseases on upper extremity function [103]. DASH is a 30-item questionnaire with response options presented as a 5-point Likert scale. Scores range from 0 (no functional limitations) to 100 (most severe functional limitations). The questionnaire is intended for patients with any upper extremity musculoskeletal disorders [104]. DASH has two optional modules (four items each) intended for athletes, musicians, and workers whose activities require special physical fitness, and functional limitations may occur only at high loads exceeding the scope of the 30 DASH items. Approved translation versions of DASH in 56 languages and dialects, including Russian, are hosted on the website of the Institute for Work and Health, which holds the copyright to the questionnaire (https://dash.iwh.on.ca/available-translations).

2) The Quick Disabilities of the Arm, Shoulder, and Hand questionnaire (QuickDASH) is a shortened 11-question version of the DASH questionnaire with the same response options [105, 106]. Like DASH, it is designed for patient self-assessment of the degree of upper extremity functional impairment in various diseases and injuries. QuickDASH also has two optional modules (four items each) intended for athletes, musicians, and workers whose activities require special physical fitness, and functional limitations may occur only at high loads exceeding the scope of the 11 QuickDASH items. The optional modules are scored separately. In several studies, a comparison of the DASH and QuickDASH questionnaires showed that both instruments have approximately equal sensitivity, specificity [107–111], and minimal clinically important difference in values (12–14 points for DASH and 12–15 points for QuickDASH) [112]. In a systematic review of 23 self-assessment instruments for patients with various upper extremity pathologies, the QuickDASH questionnaire demonstrated the highest content and construct validity, reliability, and responsiveness [113]. There are reports of successful use of QuickDASH in children aged 8–18 years [114, 115]. Approved translation versions of QuickDASH in 56 languages and dialects, including Russian, are hosted on the website of the Institute for Work and Health, which holds the copyright (https://dash.iwh.on.ca/available-translations). The Russian translation of QuickDASH in its original author version is provided in Appendix G1.

Appendix G2. Caprini Risk Assessment Model for Venous Thromboembolism

Russian title: Caprini risk assessment model for venous thromboembolism.

Original title: Caprini Score for Venous Thromboembolism

Source: Lobastov K.V., Barinov V.E., Schastlivtsev I.V., Laberko L.A. Caprini score as a tool for individual risk stratification of postoperative venous thromboembolism in high-risk group. Pirogov Russian Journal of Surgery. 2014; (12):16-23.

Type: scale

Purpose: assessment of venous thromboembolism risk

Content:

1 point

Age 41-60 years

Lower extremity edema

Varicose veins

Body mass index > 25 kg/m²

Minor surgery

Sepsis (< 1 month)

Severe pulmonary disease (including pneumonia < 1 month)

Oral contraceptive use, hormone replacement therapy

Pregnancy and postpartum period (< 1 month)

History of unexplained stillbirths, spontaneous abortions (≥3),

Premature birth with preeclampsia or intrauterine growth restriction

Acute myocardial infarction

Chronic heart failure (< 1 month)

Bed rest in a non-surgical patient

History of inflammatory bowel disease

History of major surgery (< 1 month)

Chronic obstructive pulmonary disease

2 points

Age 61-74 years

Arthroscopic surgery

Malignant neoplasm

Laparoscopic surgery (duration > 45 min)

Bed rest > 72 h

Limb immobilization (< 1 month)

Central venous catheterization

Major surgery (duration > 45 min)

3 points

Age > 75 years

Personal history of VTE

Family history of VTE

Factor V Leiden mutation

Prothrombin G20210A mutation

Hyperhomocysteinemia

Heparin-induced thrombocytopenia

Elevated anticardiolipin antibodies

Lupus anticoagulant

5 points

Stroke (< 1 month)

Multiple trauma (< 1 month)

Major joint arthroplasty

Femur and lower leg fractures (< 1 month)

Spinal cord injury/paralysis (< 1 month)

Key: Depending on the score obtained from history taking and patient examination, the patient is assigned to a specific risk group:

low risk: 0-1 point;

moderate risk: 2 points;

high risk: 3-4 points;

very high risk: 5 points or more.

Appendix G3 Revised Cardiac Risk Index (rRCRI)

Russian title: Reconstructed Revised Cardiac Risk Index for noncardiac surgical procedures

Original title: Reconstructed Revised Cardiac Risk Index (rRCRI)

Source: Davis C., Tait G., Carroll J. et al. The Revised Cardiac Risk Index in the new millennium: a single-centre prospective cohort re-evaluation of the original variables in 9,519 consecutive elective surgical patients. Can. J. Anaesth. 2013; 60(9): 855-863.

Type: scale

Purpose: prediction of the risk of perioperative cardiac complications in noncardiac surgery: myocardial infarction, pulmonary edema, ventricular fibrillation or cardiac arrest, complete AV block.

Content:

1. High-risk surgery (thoracic, major abdominal, or vascular surgery above the groin) – 1 point.

2. Coronary artery disease (myocardial infarction, positive stress test, angina, nitroglycerin use, pathological Q wave on ECG) – 1 point.

3. Heart failure (history of heart failure, pulmonary edema, paroxysmal nocturnal dyspnea, bilateral rales, gallop rhythm, pulmonary congestion on chest X-ray) – 1 point.

4. TIA/Stroke – 1 point.

5. Creatinine clearance <30 ml/min – 1 point

Scoring:

• total score of 0 – low risk of cardiovascular complications;

• a total score of 1 – moderate risk of cardiovascular complications;

• a total score of 2 or more – high risk of cardiovascular complications.

Notes:

The RCRI index was developed in 1977 [119] to predict the risk of perioperative cardiac complications in non-cardiac surgery. It was validated in the Lee study [120], and in 2013 [121] it was revised and revalidated based on clinical risk factors (instead of the criterion "creatinine level >176.8 µmol/L", the scale uses the criterion "creatinine clearance <30 ml/min"; the clinical criterion "insulin-dependent diabetes mellitus" was removed), which is why it is called the reconstructed index. It includes 5 parameters, each assigned 1 point. This specific version of the index is recommended by the Russian Society of Cardiology [24].