Proximal forearm fractures: clinical guidelines

List of Abbreviations

EFA – external fixation apparatus

AO – Association for Osteosynthesis

VTE – venous thromboembolism

RH – radial head

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

PUL – proximal ulna

PRL – proximal radius

SWD – surgical wound debridement

SCT – spiral computed tomography

RF – risk factors

PRM – physical and rehabilitation medicine

FS – functional status

Surgical antibiotic prophylaxis

TENS – transcutaneous electrical nerve stimulation

LCP – locking compression plate

ORIF – open reduction internal fixation

Terms and Definitions

Absolute stability – absence of micromotion at the fracture site, provided there is anatomical reduction and interfragmentary bone compression after fixation with hardware.

Allograft – bone tissue fragment from another human (donor), typically cadaveric, that has undergone preservation.

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).

Autograft – a fragment of the patient's own bone harvested from a donor site for transplantation to fill a bone tissue deficit (bone defect).

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

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

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

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

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).

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

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.

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.

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

1. Brief information on the disease or condition

1.1 Definition of the disease or condition

Fractures of the proximal forearm (PPF) is a term encompassing extra-articular and intra-articular fractures of the upper third of the ulna, the upper third of the radius, and combinations thereof. These fractures represent a disruption of the integrity of the forearm bones in the region of the proximal metaepiphyses due to trauma. This concept also includes forearm fracture-dislocations, as a radial head fracture may be accompanied by its dislocation, or a fracture of the upper third of the ulna may be combined with dislocation of the radial head (RH). According to the number of fragments, proximal forearm fractures are divided into simple and comminuted.

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

Fractures of the proximal ulna can result from both direct and indirect trauma. In a direct trauma mechanism, the force is applied directly to the fracture site. An indirect trauma mechanism is characterized by the application of the traumatic force at a distance from the fracture site.

High- and low-energy proximal forearm fractures are distinguished. High-energy fractures are characterized by a large number of bone fragments in the fracture zone and concomitant damage to surrounding soft tissues. Such injuries occur as a result of road traffic accidents, falls from a height, and sports activities. Low-energy fractures most frequently occur from a standing height fall, while the biology of local soft tissues remains relatively undisturbed.

Proximal radial fractures more commonly result from indirect trauma caused by a fall onto an outstretched or slightly elbow-flexed upper extremity. Proximal ulnar fractures may be caused by indirect or direct trauma. In the latter case, due to the subcutaneous location of the ulna, there is a high risk of open fractures [1, 2].

1.3 Epidemiology of the Disease or Condition

Elbow region fractures account for 7% of all fractures in the adult population [2]. Proximal radial fractures are among the most common injuries of the elbow joint, occurring at a rate of 28–39 cases per 100,000 population per year. Women over 50 years of age with developing osteoporosis are most susceptible to this injury. The second largest group of patients consists of young men, in whom proximal radial fractures result from high-energy trauma.

Proximal ulnar fractures account for 10% of all upper extremity fractures. Olecranon fractures are most frequently diagnosed in patients [1].

Elbow region fractures are among the most common fractures in children, accounting for 5–10% of all pediatric fractures. The peak incidence occurs at 6 years of age, with a male predominance over females [3, 4]. Fractures involving the growth plate account for 15–18% of all fractures in children [5]. Radial head and neck fractures account for 1–5% of all elbow fractures, with Salter-Harris type II fractures being the most common, observed in children aged 9–10 years [6].

Since the radial head in children is cartilaginous, it is more resistant to trauma; therefore, isolated radial head fractures and epiphyseal separations are rare. Radial neck fractures are the most frequent. In 30–50% of severe displaced radial neck fractures, they are combined with fractures of the olecranon, lateral condyle, medial epicondyle, or ulna [7]. Forearm dislocation combined with a radial head fracture occurs in less than 6% of elbow fractures in children [6].

Olecranon fractures are uncharacteristic for children and typically occur in combination with radial head and neck fractures [4]. Fractures of this localization account for 5% of elbow fractures and are most common in children aged 7–11 years as a result of direct trauma. Coronoid process fractures account for less than 1% of elbow fractures and virtually never occur as isolated injuries. They are usually combined with ulnar dislocation [6].

1.4 Features of Coding the Disease or Condition

S52.0 – Fracture of upper end of ulna;

S52.00 – Closed fracture of upper end of ulna;

S52.01 – Open fracture of upper end of ulna;

S52.1 – Fracture of upper end of radius;

S52.10 – Closed fracture of upper end of radius;

S52.11 – Open fracture of upper end of radius;

S52.7 – Multiple fractures of forearm;

S52.70 – multiple forearm fractures;

S52.71 – multiple open forearm fractures;

S53.0 – dislocation of radial head;

T92.1 – Sequelae of fracture of upper extremity, excluding wrist and hand.

1.5 Classification of the disease or condition

The Mason classification of radial head fractures was proposed in 1954 and modified in 1962. According to this classification, there are 4 types:

- Type 1 – nondisplaced fracture;

- Type 2 – displaced fracture;

- Type 3 – comminuted displaced fracture;

- Type 4 – radial head fracture associated with forearm dislocation.

According to the Judet classification (modified Metaizeau classification), there are 4 degrees of proximal radial epiphysis/metaphysis fractures [8]:

Grade 1 – no displacement, no angular deformity,

Grade 2 – displacement by 2/3 of the radial shaft width, angular deformity up to 30°,

Grade 3 – significant displacement, angular deformity from 30° to 60°;

Grade 4 – complete displacement, angular deformity of 60–90°, rupture of the annular ligament.

According to O'Brien's classification [9], proximal radial fractures in children are subdivided into three types:

Type I – fractures with deviation of less than 30°,

Type II – deviation of 30–60°,

Type III – deviation of more than 60°.

The most common classification of olecranon fractures is the Mayo classification, divided into 3 groups with each group further subdivided into two subgroups: A (simple fractures) and B (comminuted fractures).

- Type I – nondisplaced fracture (displacement ≤2 mm):

• A – simple nondisplaced fracture;

• B – comminuted nondisplaced fracture.

- Type II – displaced, stable fracture (displacement >2 mm):

• A – simple displaced, stable fracture;

• B – comminuted displaced, stable fracture.

- Type III – displaced, unstable fracture:

• A – simple displaced, unstable fracture;

• B – comminuted displaced, unstable fracture.

In children with olecranon fractures, the J.G. Matthews classification [10, 11] is used, comprising 4 groups:

- Group I includes simple nondisplaced fractures without associated injury;

- II group includes simple undisplaced fractures or angular fractures associated with other elbow joint fractures;

- III group includes simple undisplaced or minimally displaced fractures associated with soft tissue injury;

- IV group includes displaced fractures with an interfragmentary gap of more than 4 mm.

J.A. Ogden (1982) distinguishes three types of injuries in proximal radius and ulna fractures: total metaphyseal fractures (extra-articular), articular fractures (intra-articular), and coronoid process fractures [12].

V.A. Papavassiliou et al. (1987) subclassify olecranon fractures into intra-articular and extra-articular [13].

S.C. Graves and S.T. Canale identified three types of olecranon fractures: type I with displacement less than 5 mm, type II with displacement greater than 5 mm, and open fractures [14].

The classification by M.C. Evans and H.K. Graham (1999) is based on the anatomical location of the fracture (epiphyseal, metaphyseal, and coronoid), fracture configuration (transverse, oblique, and longitudinal), intra-articular displacement (less than 2 mm, between 2 and 4 mm, and greater than 4 mm), and the presence of associated trauma [15].

The universal classification of fractures is the AO classification, in which the proximal ulna is designated as 2U1 (u = ulna). Fractures are divided into extra-articular (avulsion, meta-epiphyseal) and intra-articular. Intra-articular fractures are further divided into two groups: Group "B" includes isolated olecranon or coronoid process fractures, and Group "C" includes unstable fractures and fracture-dislocations with combined fractures of the aforementioned anatomical structures. Additionally, following the 2018 revision, qualifiers were added to the type B olecranon fracture group: d (simple), e (comminuted). In the type B coronoid process fracture group, the following qualifiers were added: n (involving the concave part of the articular facet), o (involving the tip of the coronoid process), p (fracture less than <50%), q (fracture greater than or equal to ≥50%). In the type C fracture group, the following qualifiers were added: d (simple), r (comminuted olecranon), s (comminuted fracture involving the coronoid process):

2R1А – extra-articular fracture of the proximal radius and ulna:

2R1А1 – avulsion fracture of the radial tuberosity;

2R1А2 – simple fracture of the radial neck;

2R1А3 – complex fracture of the radial neck.

2R1В – partial intra-articular fracture of the proximal radius and ulna:

2R1В1 – simple partial intra-articular fracture of the capitulum humeri;

2R1В3 – complex partial intra-articular fracture of the capitulum humeri.

2R1С – complete intra-articular fracture of the proximal radius and ulna:

2R1С1 – simple complete intra-articular fracture of the capitulum humeri;

2R1С3 – complex complete intra-articular fracture of the capitulum humeri.

2U1A – extra-articular fracture of the proximal ulna:

2U1А1 – avulsion fracture of the triceps tendon insertion site;

2U1А2 – simple extra-articular fracture of the ulna;

2U1А3 – complex extra-articular fracture of the ulna.

2U1В – partial intra-articular fracture of the proximal ulna:

2R1В1 – fracture of the olecranon;

2R1В3 – fracture of the coronoid process.

2U1С – complete intra-articular fracture of the proximal ulna:

2R1С3 – fracture of the olecranon and coronoid process [18].

For open forearm bone fractures, the classification by R.B. Gustilo, J.T. Anderson (1976) [19] as modified by R.B. Gustilo et al. (1984) [20] 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.

In children with open growth plates of tubular bones, the Salter-Harris classification is used, which includes 5 primary (most common) and 4 additional (5–9) (rare) fracture types [5].

- Salter-Harris I: physeal fracture (fracture line extends directly through the growth plate);

- Salter-Harris II: metaphyseal-physeal fracture (fracture line extends through the physis and exits through the metaphysis) (most common fracture type);

- Salter-Harris III: epiphyseal fracture (fracture line extends from the joint through the physis into the epiphysis);

- Salter-Harris IV: osteochondral/metaphyseal-epiphyseal fracture (fracture line extends across the metaphysis, growth plate, and epiphysis);

- Salter-Harris V: crush injury to the growth plate (compression fracture of the physis);

- Salter-Harris VI: injury to the perichondral structures at the periphery of the growth plate;

- Salter-Harris VII: isolated local injury to the growth plate;

- Salter-Harris VIII: isolated injury to the metaphysis above the growth plate carrying a risk of partial growth plate closure and bone deformity;

- Salter-Harris IX: periosteal injury.

For long bone fractures in pediatric patients, the AO pediatric long bone fracture classification is used [16, 17]. According to this classification, proximal forearm fractures are categorized into the following types.

- Epiphyseal:

• 21r-E/1.1 I Epiphyseal separation (Salter-Harris I), without angular deformity or displacement;

• 21r-E/1.1 II Epiphyseal separation (Salter-Harris I), with angular deformity and displacement up to half of the bone diameter;

• 21r-E/1.1 III Epiphyseal separation (Salter-Harris I), with angular deformity and displacement greater than half of the bone diameter;

• 21r-E/2 Epiphyseal separation with metaphyseal wedge (Salter-Harris II);

• 21r-E/2.1 I Epiphyseal separation with metaphyseal wedge (Salter-Harris II), without angular deformity or displacement;

• 21r-E/2 II Epiphyseal separation with metaphyseal wedge (Salter-Harris II), with angular deformity and displacement up to half of the bone diameter;

• 21r-E/2 III Epiphyseal separation with metaphyseal wedge (Salter-Harris II), with angular deformity and displacement greater than half of the bone diameter;

• 21r-E/3 Epiphyseal fracture (Salter-Harris III);

• 21r-E/3+4 Epi(meta)physeal fracture (Salter-Harris III+IV);

- Simple epiphyseal fractures (21r-E/3.1) – fractures with an epiphyseal fragment;

- Comminuted fractures with complete separation of the epiphysis and metaphysis (21r-E/3.2) are rare;

- 21r-E/4 Epimetaphyseal fracture (Salter-Harris IV);

- Simple epiphyseal fractures (21-E/4.1) – fractures with an epiphyseal fragment with an attached metaphyseal fragment;

- Comminuted fractures (fragmentary metaphyseal; 21r-E/4.2) are rare:

• 21r-M/3 Complete;

• 21r-M/3.1 I Complete fracture, without angular deformity or displacement;

• 21r-M/3 II Complete fracture, with angular deformity and displacement up to half of the bone diameter;

• 21r-M/3 III Complete fracture, with angular deformity and displacement greater than half of the bone diameter.

These fractures can be simple (M/3.1 III) or fragmentary metaphyseal (M/3.2 III).

1.6 Clinical presentation of the disease or condition

Complaints: pain in the elbow region, impaired upper extremity function, deformity in the upper third of the forearm or elbow region, wound pain (in open fractures).

Anamnesis: history of trauma, the patient describes a characteristic mechanism of injury. Most commonly, the mechanism is indirect – a fall from standing height onto an outstretched arm. High-energy trauma (such as motor vehicle accidents or falls from a height) is characterized by greater severity and may be associated with injuries to other body segments or regions; therefore, a thorough history and physical examination are mandatory.

Objective examination: swelling of the elbow region, smoothed contours, limitation of active and passive ranges of motion due to severe pain, forced limb posture, marked tenderness upon palpation in the upper third of the forearm, abnormal mobility in the fracture area, and possible crepitus of bone fragments during passive motion.

2. Diagnostics, medical indications and contraindications for diagnostic methods

Criteria for establishing the diagnosis/condition:

• anamnestic data: history of a characteristic upper extremity trauma mechanism (fall, 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 findings: radiographic signs of fracture based on ulna and radius X-rays in 2 projections. Additional CT scan of the bone may be performed as ordered by the on-duty or attending orthopedic trauma surgeon to clarify the fracture pattern and determine the degree of fragment displacement.

2.1 Complaints and Anamnesis

In most cases, patients present with complaints described in Section 1.6 "Clinical Presentation"

2.2 Physical Examination

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

• The orthopedic trauma surgeon is recommended to evaluate the following parameters no later than 1 hour after hospital admission for diagnostic purposes, with mandatory documentation of the results in the medical records:

- assessment of somatic status;

- visual and palpation assessment of local status [21, 22, 23].

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

- measurement of blood pressure in peripheral arteries;

- general thermometry;

- assessment of venous thrombosis risk and pulmonary embolism risk (Appendix 15.2) [24].

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

• When deciding on surgical treatment for a proximal forearm fracture, it is recommended to take a history and perform a physical examination to identify risk factors and cardiovascular diseases [26, 28].

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

Comment: Risk factors for cardiovascular disease include: arterial hypertension, smoking, dyslipidemia (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, and a family history of premature cardiovascular disease (<55 years for men and <65 years for women) [11]. Established cardiovascular disease includes: coronary artery disease, cerebrovascular disease, peripheral arterial disease, chronic heart failure, pulmonary hypertension, valvular heart disease, and cardiomyopathies [27, 28].

• All patients scheduled for elective surgical treatment of a proximal forearm fracture are recommended to undergo preoperative cardiovascular risk assessment, taking into account the type of planned surgical procedure regardless of concomitant pathology, in order to prevent potential complications [26, 29].

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

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

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

• To assess the risk of perioperative cardiovascular complications in adult patients, it is recommended to use a specific algorithm [see Appendix B] [29, 31].

BMR BLEL 3Level of recommendation validity B (level of evidence – 3).

• Elective surgical treatment of a proximal forearm fracture is recommended without additional testing in patients whose cardiovascular risk is classified as low. In patients with intermediate or high perioperative cardiovascular risk, functional status assessment is recommended [30, 32].

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

2.3 Laboratory Diagnostics

• For all adult patients with an established diagnosis of proximal forearm fracture when indications for surgical treatment are present, it is recommended to perform the following laboratory tests for diagnostic purposes:

- complete blood count;

- urinalysis;

- general-profile blood biochemistry test: determination of total bilirubin level in the blood, determination of aspartate aminotransferase activity in the blood, determination of aspartate aminotransferase activity in the blood, determination of urea level in the blood, determination of creatinine level in the blood, determination of total protein level in the blood, determination of glucose level in the blood;

- determination of antibodies to Treponema pallidum in the blood;

- determination of antibodies of classes M and G (IgM, IgG) to human immunodeficiency virus HIV-1/2 and p24 antigen (Human immunodeficiency virus HIV 1/2 + Agp24) in the blood;

- determination of antibodies to hepatitis B surface antigen (HBsAg) in the blood;

- determination of antibodies to hepatitis C virus (Hepatitis C virus) in the blood;

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

- coagulogram (exploratory hemostasis test) with determination of the international normalized ratio (INR) [33, 34].

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

• When deciding on surgical treatment for a proximal forearm fracture, it is recommended to measure the blood level of N-terminal pro-B-type natriuretic peptide (NT-proBNP) in patients with intermediate or high risk of cardiovascular complications and low functional status (see Appendix 15.3) [26, 30, 35, 36].

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

2.4 Instrumental Diagnostics

• For all patients with suspected proximal forearm fracture, it is recommended to perform radiography of the elbow joint in two standard projections for diagnostic purposes [1, 21, 22, 38].

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

Comments: Radiography of the elbow joint is necessary to establish the diagnosis of a proximal forearm fracture, determine the fracture pattern and degree of fragment displacement, as well as to rule out injuries of the segment at other levels. As part of the radiological examination, radiographs in oblique projections, such as the radial head view, may be performed for better visualization of bone fragments and fracture lines [1, 21, 38].

In children, the diagnosis of proximal forearm fractures is difficult on elbow radiography due to the presence of ossification centers of the radial head and the olecranon process of the ulna [37]. Therefore, for correct interpretation of the obtained data, radiography of the contralateral elbow joint should also be performed [6].

After confirmation of a proximal forearm fracture by diagnostic imaging methods, the patient should be hospitalized in an inpatient facility if indicated; if there are no indications for hospitalization, the patient may be discharged for outpatient treatment at their place of residence.

If a patient refuses inpatient treatment, the reason for refusal must be documented in the medical records with the personal signature of the patient or their legal guardians (in cases of legally established incapacity of the patient).

Comments: MSCT provides the orthopedic trauma surgeon with additional information on the fracture pattern, degree of fragment displacement, and severity of articular surface damage, thereby significantly improving the quality of preoperative planning.

• For all patients with a fracture or suspected fracture of the proximal forearm, it is recommended to perform magnetic resonance imaging of the joints (one joint – elbow) to diagnose injuries to the ligamentous apparatus, interosseous membrane, and surrounding soft tissues [39–41].

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

• Echocardiography may be considered before planned surgical treatment of a proximal forearm fracture in patients with low functional status, elevated NT-proBNP levels, left ventricular systolic dysfunction, cardiomyopathies, heart defects, newly detected heart murmurs, and suspected cardiovascular disease [30, 45, 46].

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

2.5 Other Procedures

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

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

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

- Initial general practitioner consultation (examination) (initial pediatrician consultation (examination)): in the presence of concomitant medical conditions (according to history) [47].

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

• If acute or unstable clinical conditions are identified, it is recommended to postpone elective surgical treatment of the proximal forearm fracture and transfer the patient to a regional vascular center or specialized cardiology department to improve cardiac status and stabilize the patient's condition [30].

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 patients with proximal forearm fractures upon admission to the hospital, it is recommended to provide the following minimum scope of care in the emergency department to stabilize their general condition:

- ensuring thermal comfort for the patient;

- adequate pain management;

- immobilization of the injured upper extremity;

- correction of fluid and electrolyte imbalances [47, 57].

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

Comments: Conservative treatment can be used in patients with radial head fractures without fragment displacement or with minimal fragment displacement (less than 2 mm), as well as stable fractures. In this case, it is recommended to apply an immobilization bandage for bone fractures (sling) for 3 weeks [49] with early active motion in the elbow joint. Detection of elbow joint blockage during supination and pronation of the forearm is an indication for surgical treatment [1, 21, 48].

- extra-articular proximal ulna fractures without fragment displacement;

- incomplete intra-articular proximal ulna fractures without injury to the forearm extensor structures;

- displaced olecranon fractures in patients with reduced mobility [1, 38].

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

• In children with proximal forearm fractures with angular deformity up to 30°, it is recommended to use conservative treatment by immobilizing the limb in pronation with a plaster splint for 4 weeks [6, 50–52].

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

• In children with distal humeral epiphyseal/metaphyseal fractures without displacement or with minimal displacement up to 2 mm, conservative treatment of extra-articular fractures is recommended [53].

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

Comments: In modern scientific literature, authors emphasize the importance of early functional movements in the elbow joint in the case of conservative treatment of patients with distal humeral fractures [1, 21, 38, 48]. Even in the event of nonunion, the strategy of early functional loading allows achieving satisfactory elbow function [1].

Analgesia

• For the purpose of adequate analgesia in patients with distal humeral fractures in the postoperative period, 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 its prescription is impossible, monotherapy is recommended [54–56, 146].

Adults – Levele of recommendation A (level of evidence – 2).

Children – Level of recommendation C (level of evidence – 5).

Comments: Multimodal analgesia (MMA) involves the use of several analgesics (opioid and non-opioid) with different mechanisms of action and non-pharmacological interventions aimed at targeting the peripheral and/or central parts of the nervous system [57]. Such a combination allows for more effective pain relief by enhancing the effects of various drugs, which in most cases leads to a decrease in the frequency of prescription and/or doses of opioid analgesics. Thus, MMA reduces the risk profile of each drug while providing synergistic pain control using different classes of drugs. Postoperative MMA may include psychotherapy, physical therapy, NSAIDs, paracetamol**), gabapentinoids, regional anesthesia (single injection or placement of peripheral nerve catheters), local injections, and opioids [55, 58].

In modern scientific literature, authors emphasize the use of the lowest effective doses of opioids for the shortest possible period of time, avoiding extended-release opioids. As an adjuvant during MMA in adult patients, a single intravenous administration of #dexamethasone** 1.25–20 mg can be used before surgery (60 minutes prior to incision), which provides a significant reduction in pain [54].

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 analgesics are listed in Appendices A3.1-A3.3.

Surgical antimicrobial prophylaxis

• In the surgical treatment of patients with closed distal humeral fractures, it is recommended to perform surgical antimicrobial prophylaxis (SAP) of surgical site infection by a single preoperative administration of a systemic antibacterial drug to reduce the risk of infectious complications [59, 60].

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

Comments. In accordance with international clinical guidelines for the prevention of surgical site infections [59, 61], the objective of SAP is to create bactericidal concentrations of a systemic antibacterial drug in tissues exposed to microbial contamination during surgery to prevent surgical site infections. The necessity of SAP is determined by the surgical wound class of the upcoming operation: SAP is not required for "clean" surgical wounds not associated with the installation of orthopedic implants and metal structures. SAP should be performed for clean-contaminated and contaminated surgical wounds, as well as for "clean" surgical wounds involving the placement of orthopedic implants and metal structures. For infected ("dirty") wounds, SAP is not indicated, and antibiotic therapy is performed instead.

• In patients with distal humeral fractures, it is recommended to use first- and generation cephalosporins (I and II generation, ATC J01DB, J01DC) (cefazolin**, cefuroxime**) as the main drugs for surgical antimicrobial prophylaxis during surgical interventions in traumatology and orthopedics, and glycopeptide antibacterial drugs (vancomycin**), lincosamides (#clindamycin**) as an alternative in case of beta-lactam allergy [59]. The use of these drugs is carried out taking into account age restrictions 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 main antibacterial drugs for SAP in traumatological and orthopedic surgeries in adults: cefazolin** 2 g (for patient weight ≥120 kg – 3 g), cefuroxime** 1.5 g, #clindamycin** 900 mg, vancomycin** 15 mg/kg as a slow IV 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 [144, 145].

Comments. In open fractures, prophylactic administration of antibiotics is effective in preventing early infection, and the drug should be administered as soon as possible after trauma. Cefazolin** is the antibiotic of choice; however, in patients with high-energy open fractures with displacement and segmental bone loss, major vascular injury, and heavily contaminated wounds, it is advisable to broaden the spectrum of administered antibiotics to target gram-negative pathogens. In such cases, adult patients may be considered for the addition of #gentamicin# (at a dose of 6 mg/kg once daily) to cefazolin** [63, 64]. An alternative to this combination for patients over 18 years of age may be #ampicillin+sulbactam** (at a dose of 3.0 g every 8 hours for 3 days) [65]; the latter is particularly relevant in cases of risk of clostridial infection. According to the majority of researchers, in Gustilo and Anderson type III open fractures, antibiotics should not be continued for more than 72 hours after soft tissue wound closure [66].

Thromboprophylaxis

Comments. Taking into account the growth in the population of carriers of genetically determined thrombophilias (antithrombin III, protein C, S deficiency, factor V Leiden mutation, prothrombin G20210A mutation, etc.), widespread and often uncontrolled use of estrogens, population aging, increasing incidence of diabetes and other metabolic disorders that increase the risk of VTE, pharmacological thromboprophylaxis may be advisable in the treatment of patients with additional VTE risk factors for humeral and forearm fractures, as well as extensive soft tissue trauma 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 prescription of low molecular weight heparins (LMWH) for this category of patients according to the regimens and dosages given in Appendix 12.3 for a period of 7–10 days (until hospital discharge) or for several days until the recovery of normal/expected physical activity is possible.

Recommended medications and thromboprophylaxis regimens are given in Appendix A3.4.

Issues of VTE prophylaxis in trauma and orthopedic patients are discussed in detail in the 2022 guidelines [24] and the 2023 Russian expert guidelines [69].

Features of thromboprophylaxis in pediatric patients

• In hospitalized patients older than 6 months, it is recommended to assess bleeding and VTE risks within 24 hours of hospitalization [71] and periodically during the hospital stay [72–74].

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

Comment. Validated scales for VTE risk assessment in pediatric patients have not been developed, nor have scales for bleeding risk assessment during antithrombotic therapy; therefore, when deciding on VTE prophylaxis, individual bleeding risk factors (Appendix A3.5), VTE risk factors (Appendix A3.6), and the risk-benefit ratio should be considered [75, 77].

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 [79, 80].

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

Comment. For pediatric patients, the use of LMWH is preferred [79, 80], but currently in Russia the use of all LMWHs in children is contraindicated, so their prescription is only possible by decision of a medical commission (off-label use) (Appendix 12.4). Some foreign guidelines indicate the use of direct oral anticoagulants (rivaroxaban**) for VTE prophylaxis in children [77], however, there is currently insufficient clinical evidence of their efficacy and safety in this category of patients [76, 78].

Blood-conserving technologies

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

Comments. Systematic reviews and meta-analyses demonstrate that perioperative use of intravenous iron preparations, particularly ferric carboxymaltose, in orthopedic trauma patients, especially in the postoperative period, is an effective alternative to blood transfusion, as it reduces the proportion of patients who underwent blood transfusion, decreases the volume of transfused red blood cell mass, leads to a lower incidence of infectious complications, but does not lead to a change in mortality rates [85, 86].

3.2 Surgical Treatment

The combination of a proximal forearm fracture with a forearm dislocation requires emergency reduction of the dislocation. A feature of these injuries is that the forearm bone fracture is accompanied by damage to the capsule-ligamentous apparatus, the integrity of which must also be surgically restored if instability persists after osteosynthesis. After reduction of the forearm dislocation, brief immobilization of the upper extremity is permitted if severe instability of the elbow joint persists when emergency surgery is impossible. In open fractures, except for cases of extensive wound contamination, primary surgical debridement of the wound with internal fixation of fragments is required. In closed injuries, soft tissue edema is not a contraindication to surgical treatment. The following surgical approaches are used for osteosynthesis of proximal forearm fractures: the posterior approach to the olecranon, the Kocher approach to the radial head (the incision is made along the lateral surface of the elbow joint from the humeral epicondyle and extends distally along the lateral surface of the forearm in the projection of the head and neck of the radius, the approach is made between the anconeus and the extensor carpi ulnaris), the Hotchkiss approach to the coronoid process (a skin incision is made along the medial surface of the elbow joint in the projection of the humeral epicondyle [1].

- intra-articular fractures with fragment displacement of more than 2 mm;

- fractures with fragment displacement combined with dislocation in the humeroradial and/or proximal radioulnar joint;

- presence of free bone fragments in the joint cavity;

- unstable fractures;

- fractures as part of polytrauma, open fractures, fractures associated with neurovascular disorders [1].

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

• In children, surgical treatment of proximal forearm fractures is recommended in case of an unsatisfactory position of fragments after a previously performed closed reduction, in case of complete displacement of the radial head, as well as angular deformity of fragments >60° [4, 6, 50-52].

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

Comments:

Proximal forearm fractures in children with a displacement of more than 2 mm are an indication for surgical treatment. For moderately displaced fractures and unstable minimally displaced fractures that re-displace after closed reduction, closed reduction and percutaneous Kirschner wire fixation (orthopedic bone wire***) are indicated. Indications for open reduction include severely displaced fractures or irreducible fractures [53].

The main objective of surgical treatment of proximal forearm fractures is stable fixation to allow early rehabilitation in the postoperative period. Intra-articular fractures, in addition to stable osteosynthesis, require anatomical reduction and interfragmentary compression to create optimal conditions for fracture healing, as well as to initiate early functional movements in the elbow joint after surgical treatment. It is early mobilization of the injured extremity that directly affects the functional outcome of treatment in patients with such injuries [1, 21, 48]. In children, residual angular deformity at the level of the radial neck of 30-50° does not cause significant impairment and spontaneously corrects during the child's growth over 3-4 years [6].

Comments: Complicated proximal forearm fractures constitute a group of injuries that, in the absence of proper treatment, lead to poor functional outcomes. This category of trauma is characterized by a combination of a proximal forearm fracture with a forearm bone dislocation accompanied by injury to the ligamentous apparatus and/or the interosseous membrane. Therefore, intraoperatively, after performing osteosynthesis of the forearm bones, it is necessary to verify the stability of the elbow joint. If there are doubts, it is recommended to repair the damaged structures of the ligamentous apparatus—the annular ligament, ulnar and radial collateral ligaments. Such injuries include:

- olecranon fracture combined with anterior dislocation of the ulna—typically a high-energy trauma; the olecranon fracture is comminuted and may be combined with a coronoid process fracture;

- posterior Monteggia fracture-dislocation—olecranon fracture combined with radial head fracture and posterolateral dislocation of the radial head; restoration of ulnar length and osteosynthesis of the olecranon allows for the reduction of the radial head dislocation, followed by its osteosynthesis, resection, and/or arthroplasty;

- fracture of the coronoid process and radial head combined with forearm dislocation—this injury is known in the literature as the "terrible triad", which is due to the fact that in earlier stages of surgical technique development, it was believed that the functional outcome of treatment in patients with such an injury would be highly likely poor;

- Essex-Lopresti fracture—a combination of radial head fracture, interosseous membrane injury, and distal radioulnar joint disruption; due to the damaged distal and proximal radioulnar joints, there is a pronounced impairment of forearm and elbow function resulting from a "floating" radial diaphysis [1, 21].

• In patients with diagnosed radial head dislocation, it is recommended to perform additional diagnostic imaging to identify all injured anatomical structures in order to clarify the diagnosis [1, 18].

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

Comments: Isolated radial head dislocation is extremely rare. As a rule, such an injury is combined with a fracture of one or both forearm bones at some level. Therefore, to restore anatomical relationships in the radiohumeral joint, osteosynthesis of the forearm bone fracture(s) must be performed first [1, 18].

3.2.1 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***.

Surgical fixation of radial head fractures, according to a number of authors, reduces the risk of degenerative changes in the elbow joint [21, 87]. Partial intra-articular radial head fractures can be stabilized using Herbert screws, the insertion of which involves countersinking the screw head into the articular surface, thus creating no mechanical obstruction during joint movement. For extra-articular fractures of the radial neck with displaced fragments or complex intra-articular radial head fractures, plate and screw osteosynthesis is performed. These hardware constructs should be placed along the posterolateral surface of the radius and radial head, as this will avoid conflict between the plate and the articular surface of the ulnar notch [1, 21, 48].

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 is widely used for the fixation of unstable olecranon fractures with fragment displacement. In intra-articular fractures, the primary objective is the restoration of the articular surface of the olecranon. Anatomically pre-contoured locking compression plates provide the widest capabilities for traumatologists to fix small fragments [1, 38].

3.2.2 Tension band wiring

Comments: When performing forearm bone osteosynthesis using the tension band technique, the following implants are used: orthopedic bone wire***, Kirschner wire (orthopedic bone wire***).

The tension band wiring technique allows for excellent functional outcomes in the surgical treatment of simple intra-articular olecranon fractures. The best results with this osteosynthesis method can be achieved when there is tight fragment contact along the articular surface line of the olecranon in patients with good bone quality. This variant of olecranon osteosynthesis enables the patient to initiate early functional movements in the elbow joint, which promotes rapid rehabilitation. However, this surgical treatment method often requires secondary surgical interventions to remove the hardware due to migration or causing discomfort to the patient in daily life [1, 38].

3.2.3 Intramedullary nailing

Comments: When performing forearm bone osteosynthesis using the tension band technique, the following implants are used: non-absorbable non-sterile orthopedic bone screw***, non-absorbable sterile orthopedic bone screw***, non-absorbable orthopedic bone rod***.

Intramedullary nail implantation for olecranon fractures avoids soft tissue irritation caused by wires, pins, and plates [1, 88].

3.2.4 Radial head resection

Comments: Radial head resection may be the method of choice for complex intra-articular proximal forearm fractures when osteosynthesis cannot be performed. However, several scientific publications provide data indicating that in the case of post-traumatic elbow instability due to ligamentous injury, radial head removal can lead to pronounced degenerative changes in the elbow joint, which is related to the fact that about 60% of the load is transmitted to the humerus via the radiohumeral joint [1, 21, 48]. This is supported by a study by Lindenhovius et al. (2009), in which the authors conclude that open reduction and internal fixation of radial head fractures yields superior functional outcomes and a lower incidence of post-traumatic osteoarthritis of the elbow compared to radial head resection [21, 87]. On the other hand, Antuña et al. report a high rate (92.3%) of good functional outcomes in patients following radial head resection for Mason type II and III fractures at a 15-year follow-up [21, 89].

3.2.5 Arthroplasty

Comments: When performing osteosynthesis of the forearm bones using the tension band technique, the following implants are used: radial head endoprosthesis.

Radial head endoprosthesis replacement is considered the method of choice in the treatment of patients with complex proximal forearm fractures. Nevertheless, foreign authors have not reached a consensus regarding the quality of functional results achieved with this technique. According to some data, degenerative changes after radial head replacement occur in 50% of patients, and pain persists in 47% [1, 6]. Another unresolved issue is the elongation of the radius due to the prosthesis, which leads to biomechanical disturbances in elbow joint movements and, consequently, to degenerative-dystrophic changes [1].

3.2.3 External fixation device

Comments: When applying an external fixation device to stabilize forearm fractures, the following implants are used: Schanz screw, Steinmann pin, Kirschner wire (orthopaedic bone wire***), and wire with a stopper for osteosynthesis (orthopaedic bone wire***).

3.3 Other Treatment

Comments: In accordance with clauses 4156-4157 of the Sanitary Rules and Norms on the Prevention of Infectious Diseases (SanPiN 3.3686-21), emergency tetanus prophylaxis is carried out for any injuries involving compromised integrity of the skin and mucous membranes. Emergency tetanus prophylaxis is performed up to the 20th calendar day from the moment of injury [90]. The administration of drugs for emergency tetanus immunoprophylaxis is carried out differentially depending on the availability of documented confirmation of preventive vaccination or data from immunological monitoring of anti-tetanus immunity levels, as well as taking into account the nature of the injuries.

Emergency tetanus immunoprophylaxis is carried out in the form of:

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

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

- emergency revaccination with tetanus toxoid** (or diphtheria-tetanus toxoid** with reduced antigen content – Td-toxoid) to stimulate immunity in previously vaccinated individuals. [90, 91].

4. Medical Rehabilitation and Sanatorium-Resort Treatment

Comments: during conservative treatment of a radial head fracture, olecranon fracture, coronoid process fracture, forearm dislocation, or forearm fracture-dislocation, immobilization is carried out using a plaster cast or orthosis for 3–4 weeks. The objectives of this period are to create conditions for the earliest possible fracture consolidation and to prevent elbow joint stiffness [92]. The main challenge in treating fractures of this localization is restoring the function of the elbow joint, traumatic injuries to which lead to the development of contractures that can be quite rigid in some cases and require prolonged rehabilitation [94-96].

The rehabilitation program consists of active finger movements, grasping and squeezing objects with the fingers, reflex (ideomotor) movements for the elbow joint, active assisted movements for the shoulder joint, isometric contractions of the forearm and shoulder muscles alternating with general conditioning exercises using the healthy arm. Performing light household chores is permitted.

Comments: after the removal of immobilization, the objectives of rehabilitation are to improve blood circulation in the limb, restore muscle tone and elasticity in the shoulder and forearm, improve mobility in the elbow joint, and restore self-care and arm working capacity. For the first two weeks, the rehabilitation program includes: active movements of the fingers, wrist, and shoulder joints, assisted easy movements in the elbow joint, exposure to a low-frequency pulsed electrostatic field, passive mechanotherapy, gentle passive stretching of soft tissues (positional treatment), water exercises, superficial manual massage techniques for the shoulder and forearm muscles, and electrostatic field massage [92, 93, 97, 99-102].

Two weeks after the removal of immobilization, at a follow-up visit (examination, consultation) with a physical and rehabilitation medicine physician / exercise therapy physician, the issue of prescribing dynamic exercises with additional resistance and loading for the elbow joint motor muscles is decided, along with mechanotherapy on simple, pulley, and pendulum devices for joint injuries and diseases, and motorized mechanotherapy for bone fractures. Biofeedback training based on dynamographic indicators (strength) and goniographic indicators (joint angles) in bone fractures, electrical muscle stimulation (EMS) to correct elbow joint contractures, manual therapy for bone system disorders to stretch and increase the elasticity of shoulder and forearm muscles, and training in household skills, self-care, and occupational therapy [97].

Comments: Postoperative restoration of the range of motion in the elbow joint must be initiated as early as possible, within the first 24 hours [92, 99, 101, 103, 104, 107]. After surgery, the arm is fixed in a flexed position at the elbow joint using a supportive soft removable orthosis or sling. To improve blood circulation in the limb, reduce pain and swelling, this stage of the program includes local cryotherapy, TENS [102, 103, 108], barotherapy (limb pressure therapy, pneumatic compression), passive exercises for the elbow joint within a pain-free range with fixation of flexion and extension positions (corrective positioning), motorized mechanotherapy for bone fractures and robotic mechanotherapy for bone injuries [100, 101, 106], and isometric exercises for the shoulder and forearm muscles combined with active finger and wrist movements and active assisted shoulder movements [92, 93, 97, 103, 109].

Physical therapy methods are aimed at reducing pain and swelling, relieving inflammation, and improving tissue nutrition and metabolism in the surgical area.

Early elbow joint movements: passive or using a continuous passive motion (CPM) device for the elbow joint within a pain-free range, aimed at improving and rapidly restoring joint mobility [92, 108].

Comments: Two weeks after surgery, following a repeat consultation with a physical and rehabilitation medicine (PRM) physician/exercise therapy physician and establishment of a functional diagnosis, the primary objective is addressed: restoring mobility of the elbow joint. Active movements in the limb joints, active-assisted movements in the elbow joint, shoulder and forearm muscle stretching exercises with increasing resistance and fixation of the achieved range of motion (positional correction), powered mechanotherapy devices for bone fractures, robotic mechanotherapy for bone fractures, hydrokinesitherapy for bone fractures, biofeedback training based on dynamometric parameters (strength) and goniographic parameters (joint angle) for bone fractures, self-care training, and occupational therapy are prescribed [94, 95, 99-102, 109].

During the subsequent two weeks following the follow-up appointment (examination, consultation) of a physical and rehabilitation medicine physician / exercise therapy physician, exercises are prescribed to restore muscle strength and arm performance: weighted dynamic exercises, resistance exercises, active mechanotherapy, exercise machine training, and occupational therapy [94, 95, 99-102, 109].

Comments: The literature demonstrates that, unlike other joints, traumatic injuries to the elbow joint lead to complex contractures that are difficult to recover from, often caused by soft tissue ossification [95, 96, 98, 108, 110, 112, 113]. It has been shown that all procedures enhancing blood flow in the joint area and forceful movements in the joint that overcome pain contribute to this. Therefore, the load during physical exercises should be dosed, and weighting the arm with loads should be excluded. Intensive thermal procedures and massage are not used. Massage of the elbow joint, which causes mechanical tissue irritation, is contraindicated within the first 1.5 to 2 months after injury [108].

5. Prevention and Dispensary Observation

Prevention of forearm bone fractures consists of citizens complying with 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.

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 continuing treatment and rehabilitation. This will ensure continuity between the inpatient and outpatient stages of treatment.

Follow-up examinations including radiography of the ulna and radius in conservative treatment at 5-7 days as edema subsides and at 6-8 weeks (before cast removal). In surgical treatment, examinations with radiographs and assessment of functional recovery dynamics are performed at 4-6 weeks from surgery (assessment of fracture consolidation degree and the possibility of increasing limb load), 12 weeks post-surgery (assessment of fracture consolidation degree and decision on full limb load capability), 24 weeks post-surgery (assessment of functional recovery dynamics), and 1 year post-surgery (assessment of the functional outcome of treatment and deciding on the necessity and timing of implant removal).

In children with proximal forearm fractures involving open growth plates, bone growth disturbances and premature closure of the growth plate are possible, leading to forearm deformity during the child's growth and early osteoarthritis [6, 53].

6. Organization of Medical Care

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

Objective of clinical guidelines: Clinical guidelines have been developed to improve the quality of medical care, standardize diagnostic and treatment algorithms for patients with proximal forearm fractures.

Indications for planned hospitalization:

unsatisfactory result of conservative treatment: absence of signs of proximal forearm fracture consolidation after conservative treatment or osteosynthesis surgery within 2.5–3.5 months after injury or surgery [1, 114].

Indications for emergency hospitalization:

Patients with suspected or confirmed proximal forearm fracture must be referred to a hospital to resolve the issue of emergency hospitalization. Indications for emergency hospitalization are:

- extra-articular proximal forearm fracture with fragment displacement;

- intra-articular proximal forearm fractures with fragment displacement;

- pathological proximal forearm fracture;

- combination of proximal forearm fracture with vascular or neurological disorders;

- open proximal forearm fracture;

- proximal forearm fracture as part of polytrauma;

- ipsilateral fractures of the proximal forearm and other upper extremity segments.

Indications for patient discharge from the hospital:

1. Internal fixation of the fracture with hardware or radial head arthroplasty has been performed, or adequate plaster immobilization has been achieved in 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 is required.

Criteria for Evaluating the Quality of Medical Care

References

Appendix A1. Working Group Composition

1. Agranovich O.E., MD, DSc, National Medical Research Center for Children's Traumatology and Orthopedics named after H.I. Turner of the Russian Ministry of Health, Saint Petersburg.

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

3. 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.

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. Maiorov B.A., PhD, Saint Petersburg I.I. Janelidze Research Institute of Emergency Medicine, Pavlov University, Saint Petersburg, member of ATOR.

6. Nazarenko A.G., MD, DSc, Professor of the RAS, National Medical Research Center of Traumatology and Orthopedics named after N.N. Priorov of the Russian Ministry of Health, Moscow, Vice President of ATOR.

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

8. Sergeev G.D., PhD, Saint Petersburg I.I. Janelidze Research Institute of Emergency Medicine, Saint Petersburg, member of ATOR

Conflict of interest.

The working group responsible for drafting these clinical guidelines has no conflicts 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 Practice Guideline for Acute Musculoskeletal Pain Management [132].

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 Practice Guideline for Acute Musculoskeletal Pain Management [132].

Appendix A3.3 Analgesic dosage regimen for children

¹ In children under 12 years of age, morphine** is preferred when opioid analgesics are required, as the use of tramadol** is associated with a higher risk of adverse reactions [133,134].

² Not recommended in children because its metabolite accumulates in the body and provokes seizures upon repeated administration [135].

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

Please note 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 (in this case, APTT or ACT values must be within the normal range) [136,137].

Appendix A3.5 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 consulting a hematologist if the patient is at high risk for VTE with a high bleeding risk [73].

4. Uncontrolled hypertension is defined as systolic or diastolic blood pressure above the 95th percentile for age, height, and sex [74].

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

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

Notes:

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

− A 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 the intensive care unit or critical care unit (receiving inotropic support, mechanically ventilated).

− 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

Physician's algorithm for proximal forearm fracture management

Algorithm for preoperative cardiovascular risk assessment

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 15.3);

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

Proximal forearm fractures are injuries that require specialized treatment in a trauma center or traumatology department. Conservative treatment of such injuries is only possible for non-displaced fractures. This type of treatment involves immobilization with a plaster cast or a functional elastic bandage, with early mobilization and active movements in the elbow joint. In the absence of proper rehabilitation and with prolonged immobilization, elbow contracture may develop, leading to a significant decrease in quality of life. Surgical treatment is indicated for all displaced fractures. Various plates, intramedullary nails, tension band wiring techniques, as well as radial head resection or arthroplasty, are used to treat proximal forearm fractures. Treatment can be single-stage (for isolated closed fractures with satisfactory soft tissue condition) or two-stage, where the fracture is temporarily fixed with an external fixator followed by internal fixation (for multiple and polytrauma cases, severe open fractures, and significant soft tissue injury). In all cases, the goal should be to achieve stable osteosynthesis that does not require additional external immobilization after surgery. This enables early rehabilitation treatment to be initiated.

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 trophism of damaged soft tissues and bone. The timing for allowing limb weight-bearing may vary depending on the nature of the fracture and the method of fixation. Following osteosynthesis of fractures with plates, the timing for initiating axial weight-bearing on the limb depends on the complexity of the fracture, whereas functional joint movements in the injured upper extremity are possible within the first days after surgery.

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

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 (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 [115]. 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 [116]. DASH has two optional modules (four items each) intended for athletes, musicians, and workers whose activities require specific physical conditioning, and whose functional limitations may only occur under high loads that exceed the scope of the 30 DASH items. Approved translation versions of DASH in 56 languages and dialects, including Russian, are available on the website of the Institute for Work and Health (Canada), which holds the copyright for the questionnaire (https://dash.iwh.on.ca/available-translations).

2) The shortened disabilities of the arm, shoulder and hand questionnaire (QuickDASH) is an 11-question shortened version of the DASH questionnaire with the same response options [117, 118]. Like DASH, it is designed for patients' self-assessment of the degree of upper extremity function impairment in various diseases and injuries. QuickDASH also has two optional modules (four items each) intended for athletes, musicians, and workers whose activities require specific physical conditioning, and whose functional limitations may only occur under high loads that exceed the scope of the 11 QuickDASH items. The optional modules are scored separately. In several studies, comparing the DASH and QuickDASH questionnaires showed that both instruments have approximately equal sensitivity, specificity [119-123], and minimal clinically important difference values (12-14 points for DASH and 12-15 points for QuickDASH) [124]. In a systematic review of 23 self-assessment instruments for patients with various upper extremity pathologies, the QuickDASH questionnaire showed the highest content and construct validity, reliability, and responsiveness [125]. There are reports of successful application of QuickDASH in children aged 8-18 years [126, 127]. Approved translation versions of QuickDASH in 56 languages and dialects, including Russian, are available on the website of the Institute for Work and Health (Canada), which holds the copyright (https://dash.iwh.on.ca/available-translations).

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)

Use of systemic hormonal contraceptives, 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.

Reconstructed 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 (intrathoracic, intra-abdominal, or suprainguinal vascular surgery) – 1 point.

2. Coronary artery disease (myocardial infarction, positive stress test, angina pectoris, 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 [129] to predict the risk of perioperative cardiac complications in non-cardiac surgery. It was validated in the Lee study [130], revised in 2013 [131], and re-validated based on clinical risk factors (the criterion "creatinine level >176.8 µmol/L" was replaced by "creatinine clearance <30 mL/min"; the clinical criterion "insulin-dependent diabetes mellitus" was removed), which is why it is called the revised cardiac risk index. It includes 5 parameters, each assigned 1 point. This specific version of the index is recommended by the Russian Society of Cardiology [30].