eMedicine Specialties > Emergency Medicine > Trauma & Orthopedics
Fracture, Forearm: Treatment & Medication
Updated: Mar 31, 2009
- Overview
- Differential Diagnoses & Workup
- Treatment & Medication
- Follow-up
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Treatment
Prehospital Care
Stabilize the arm to prevent or limit neurovascular injury from sharp bone fragments.
Emergency Department Care
- Immobilize the forearm and upper arm and provide effective analgesia unless the patient has other injuries with the potential for hemodynamic or respiratory instability.
- Identify other injuries. Because forearm fractures require considerable force, perform a complete physical examination to exclude other injuries.
- Assess the injured forearm.
- Perform a careful examination of the upper extremity to identify neurovascular deficits, tense muscle compartments, and disruptions of the skin.
- Obtain appropriate radiographs to define fracture(s) and evaluate for associated dislocation.
- Treat injury expeditiously.
- Provide adequate analgesia/anesthesia.
- Perform emergent reduction, if necessary. The bone ends may shift, resulting in the loss of reduction. This may occur in the first 10-14 days, or it may occur 6-8 weeks later.
- Immobilize injury.
- Administer antibiotics and tetanus immunization, as indicated.
- Immediate fracture reduction is indicated when any of the following exists:
- Neurovascular compromise
- Severe displacement
- Tenting of the skin
- ED anesthesia/analgesia options
- Axillary block provides complete anesthesia and muscle relaxation but carries the risk of arterial or nerve injury.
- Hematoma block provides anesthesia and muscle relaxation but carries the risk of osteomyelitis.
- Intravenous regional anesthesia (Bier block) provides anesthesia and muscle relaxation but carries the risk of lidocaine toxicity.
- Conscious sedation provides effective anesthesia, muscle relaxation, and amnesia. It carries the risk of respiratory depression and requires increased nursing time.
Consultations
- Consult an orthopedist for open fractures, operative fractures, or dislocations, and arrange close follow-up care.
- Fracture reductions typically are deferred to an orthopedist unless evidence of neurovascular compromise is noted.
- Insufficient evidence exists to support a specific management technique of isolated fractures of the ulna.
- Some evidence indicates that distal radius fractures may have better outcomes with external fixation or pinning than with conservative, nonsurgical management.
Medication
Drugs used to treat fractures are generally NSAIDs and analgesics. In addition, administer proper antibiotics and tetanus prophylaxis for open fractures.
Nonsteroidal anti-inflammatory agents (NSAIDs)
These drugs are used most commonly for relief of mild to moderately severe pain. Although effects of NSAIDs in the treatment of pain tend to be patient specific, ibuprofen is usually the DOC for initial therapy. Other options include flurbiprofen, ketoprofen, and naproxen.
Ibuprofen (Ibuprin, Advil, Motrin)
Usually DOC for treatment of mild to moderately severe pain, if no contraindications. Inhibits inflammatory reactions and pain, probably by decreasing activity of enzyme cyclooxygenase, inhibiting prostaglandin synthesis.
Adult
200-400 mg PO q4-6h prn; not to exceed 3.2 g/d
Pediatric
6 months to 12 years: 20-40 mg/kg/d PO divided tid/qid
>12 years: Administer as in adults
Aspirin increases risk of inducing serious NSAID-related adverse effects; probenecid may increase concentrations and, possibly, toxicity; may decrease effects of hydralazine, captopril, and beta-blockers; may decrease diuretic effects of furosemide and thiazides; may increase PT in patients taking anticoagulants—monitor PT closely and instruct patients to watch for signs of bleeding; may increase risk of methotrexate toxicity; may increase phenytoin levels
Documented hypersensitivity; peptic ulcer disease; recent GI bleeding or perforation; renal insufficiency; high risk of bleeding
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
Caution in congestive heart failure, hypertension, and decreased renal and hepatic function; caution in coagulation abnormalities or during anticoagulant therapy
Ketoprofen (Oruvail, Orudis, Actron)
Used for relief of mild to moderately severe pain and inflammation. Administer small dosages initially to patients with small bodies, older persons, and those with renal or liver disease. Doses higher than 75 mg do not increase therapeutic effects. Administer high doses with caution and closely observe.
Adult
25-50 mg PO q6-8h prn; not to exceed 300 mg/d
Pediatric
3 months to 12 years: 0.1–1 mg/kg PO q6-8h
>12 years: Administer as in adults
Aspirin increases risk of inducing serious NSAID-related adverse effects; probenecid may increase concentrations and, possibly, toxicity; may decrease effects of hydralazine, captopril, and beta-blockers; may decrease diuretic effects of furosemide and thiazides; may increase PT in patients taking anticoagulants—monitor PT closely and instruct patients to watch for signs of bleeding; may increase risk of methotrexate toxicity; may increase phenytoin levels
Documented hypersensitivity
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
Caution in congestive heart failure, hypertension, and decreased renal and hepatic function; caution in coagulation abnormalities or during anticoagulant therapy
Naproxen (Anaprox, Naprelan, Naprosyn)
Used for relief of mild to moderately severe pain. Inhibits inflammatory reactions and pain by decreasing activity of enzyme cyclooxygenase, decreasing prostaglandin synthesis.
Adult
500 mg PO followed by 250 mg q6-8h; not to exceed 1.25 g/d
Pediatric
<2 years: Not established
>2 years: 2.5 mg/kg/dose PO; not to exceed 10 mg/kg/d
Aspirin increases risk of inducing serious NSAID-related adverse effects; probenecid may increase concentrations and, possibly, toxicity; may decrease effects of hydralazine, captopril, and beta-blockers; may decrease diuretic effects of furosemide and thiazides; may increase PT in patients taking anticoagulants—monitor PT closely and instruct patients to watch for signs of bleeding; may increase risk of methotrexate toxicity; may increase phenytoin levels
Documented hypersensitivity; peptic ulcer disease; recent GI bleeding or perforation; renal insufficiency
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
Acute renal insufficiency, interstitial nephritis, hyperkalemia, hyponatremia, and renal papillary necrosis may occur; patients with preexisting renal disease or compromised renal perfusion risk acute renal failure; leukopenia occurs rarely, is transient, and usually returns to normal during therapy; persistent leukopenia, granulocytopenia, or thrombocytopenia warrants further evaluation and may require discontinuation of drug
Flurbiprofen (Ansaid, Ocufen)
Has analgesic, antipyretic, and anti-inflammatory effects. May inhibit cyclooxygenase enzyme, inhibiting prostaglandin biosynthesis.
Adult
200-300 mg/d PO divided bid/qid
Pediatric
Not established
Aspirin increases risk of inducing serious NSAID-related adverse effects; probenecid may increase concentrations and, possibly, toxicity; may decrease effects of hydralazine, captopril, and beta-blockers; may decrease diuretic effects of furosemide and thiazides; may increase PT in patients taking anticoagulants—monitor PT closely and instruct patients to watch for signs of bleeding; may increase risk of methotrexate toxicity; may increase phenytoin levels
Documented hypersensitivity
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
Acute renal insufficiency, interstitial nephritis, hyperkalemia, hyponatremia, and renal papillary necrosis may occur; patients with preexisting renal disease or compromised renal perfusion risk acute renal failure; leukopenia occurs rarely, is transient, and usually returns to normal during therapy; persistent leukopenia, granulocytopenia, or thrombocytopenia warrants further evaluation and may require discontinuation of drug
Analgesics
Pain control is essential to quality patient care. It ensures patient comfort, promotes pulmonary toilet, and enables physical therapy regimens. Many analgesics have sedating properties that benefit patients who have sustained fractures.
Acetaminophen and codeine (Tylenol #3)
Drug combination indicated for treatment of mild to moderately severe pain.
Adult
30-60 mg/dose based on codeine content PO q4-6h or 1-2 tab q4h; not to exceed 12 tab/d
Pediatric
0.5-1 mg/kg/dose based on codeine PO q4-6h; 10-15 mg/kg/dose based on acetaminophen content; not to exceed 2.6 g/d of acetaminophen
CNS depressants or tricyclic antidepressants increase toxicity
Documented hypersensitivity
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Caution in patients dependent on opiates because this substitution may result in acute opiate-withdrawal symptoms; caution in severe renal or hepatic dysfunction
Hydrocodone bitartrate and acetaminophen (Vicodin ES)
Drug combination indicated for relief of moderately severe to severe pain.
Adult
1-2 tab/cap PO q4-6h prn
Pediatric
<12 years: 10-15 mg/kg/dose acetaminophen PO q4-6h prn; not to exceed 2.6 g/d of acetaminophen
>12 years: 750 mg acetaminophen PO q4h; single dose not to exceed 10 mg of hydrocodone bitartrate; not to exceed 5 doses/d
Phenothiazines may decrease analgesic effects; CNS depressants or tricyclic antidepressants increase toxicity
Documented hypersensitivity; high-altitude cerebral edema; elevated intracranial pressure
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Tablets contain metabisulfite which may cause hypersensitivity; caution in patients dependent on opiates because this substitution may result in acute opiate-withdrawal symptoms; caution in severe renal or hepatic dysfunction
Oxycodone and acetaminophen (Percocet)
Drug combination indicated for relief of moderately severe to severe pain. DOC for aspirin-hypersensitive patients.
Adult
1-2 tab/cap PO q4-6h prn
Pediatric
0.05-0.15 mg/kg/dose oxycodone PO q4-6h prn; not to exceed 5 mg/dose of oxycodone q4-6h
Phenothiazines may decrease analgesic effects; CNS depressants or tricyclic antidepressants increase toxicity
Documented hypersensitivity
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Duration of action may increase in elderly persons; be aware of total daily dose of acetaminophen patient is receiving; do not exceed 4000 mg/24 h of acetaminophen; higher doses may cause liver toxicity
Antibiotics
Empiric antimicrobial therapy must be comprehensive and should cover all likely pathogens in the clinical setting.
Gentamicin (Gentacidin, Garamycin)
Aminoglycoside antibiotics used for gram-negative bacterial coverage. Commonly used in combination with both an agent against gram-positive organisms and one that covers anaerobes. Used in conjunction with ampicillin or vancomycin for prophylaxis in patients with open fractures.
Adult
1.5 mg/kg IV; not to exceed 80 mg
Pediatric
2 mg/kg IV
Other aminoglycosides, cephalosporins, penicillins, and amphotericin B may increase nephrotoxicity; enhances effects of neuromuscular blocking agents, thus prolonged respiratory depression may occur; loop diuretics may increase auditory toxicity—possible irreversible hearing loss of varying degrees may occur (monitor regularly)
Documented hypersensitivity; non–dialysis-dependent renal insufficiency
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Narrow therapeutic index (not intended for long-term therapy); caution in renal failure (patient not taking dialysis), myasthenia gravis, hypocalcemia, and conditions that depress neuromuscular transmission; adjust dose in renal impairment
Ampicillin (Omnipen, Marcillin)
Used for prophylaxis in patients undergoing dental, oral, or respiratory tract procedures. Interferes with bacterial cell wall synthesis during active replication, causing bactericidal activity against susceptible organisms. This drug is given in place of amoxicillin in patients unable to take medication orally. It is also used along with gentamicin for prophylaxis in patients with open fractures.
Adult
2 g IV/IM
Pediatric
50 mg/kg IV/IM
Probenecid and disulfiram elevate levels; allopurinol decreases effects and has additive effects on ampicillin rash; may decrease effects of oral contraceptives
Documented hypersensitivity
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Adjust dose in renal failure; evaluate rash and differentiate from hypersensitivity reaction
Vancomycin (Vancocin)
Potent antibiotic directed against gram-positive organisms and active against enterococcal species. Also useful in treatment of septicemia and skin structure infections. Used in conjunction with gentamicin for prophylaxis in penicillin-allergic patients undergoing GI or GU procedures. May need to adjust the dose in patients with renal impairment.
Adult
1 g IV infused over 1 h
Pediatric
1.5 mg/kg IV infused over 1 h
Erythema, histaminelike flushing, and anaphylactic reactions may occur when administered with anesthetic agents; taken concurrently with aminoglycosides, risk of nephrotoxicity may increase above that with aminoglycoside monotherapy; effects in neuromuscular blockade may be enhanced when coadministered with nondepolarizing muscle relaxants
Documented hypersensitivity
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Caution in renal failure, neutropenia; red man syndrome is caused by too rapid IV infusion (dose given over a few min) but rarely happens when dose given over 2 h or by PO or IP route; red man syndrome not an allergic reaction
Toxoid
This agent is used for tetanus immunization. A booster injection in previously immunized individuals is recommended to prevent this potentially lethal syndrome.
Tetanus toxoid
Used to induce active immunity against tetanus in selected patients. Tetanus and diphtheria toxoids are immunizing AOC for most adults and children >7 y. Necessary to administer booster doses to maintain tetanus immunity throughout life. Pregnant patients should receive only tetanus toxoid, not a diphtheria antigen-containing product. In children and adults, may administer into deltoid or midlateral thigh muscles. In infants, preferred site of administration is midthigh laterally.
Adult
Primary immunization: 0.5 mL IM, give 2 injections 4-8 wk apart and a third dose 6-12 mo after a second injection
Booster dose: 0.5 mL q10y
Pediatric
Primary immunization: 0.5 mL IM, give 2 injections 4-8 wk apart and a third dose 6-12 mo after the second injection.
Booster dose: 0.5 mL q10y
Patients receiving immunosuppressants, including corticosteroids or radiation therapy, may remain susceptible despite immunization due to poor immune response; cimetidine may enhance or augment delayed-hypersensitivity responses to skin-test antigens; avoid concurrent use of chloramphenicol because it may impair amnestic response to tetanus toxoid; concurrent use of tetanus immune globulin may delay development of active immunity by several days (interaction is nevertheless clinically insignificant and does not preclude its concurrent use)
Documented hypersensitivity; history of any type of neurological symptoms or signs following administration of this product
FDA recommends that elective tetanus immunization be deferred during any outbreak of poliomyelitis because tetanus toxoid injections are an important cause of provocative poliomyelitis
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Do not use to treat actual tetanus infections, or for immediate prophylaxis of unimmunized individuals (use instead tetanus antitoxin, preferably human tetanus immune globulin) diminished antibody response to active immunization may be seen in patients receiving immunosuppressive therapy; better to defer primary diphtheria immunization until immunosuppressive therapy discontinued; routine immunization of symptomatic and asymptomatic HIV-infected persons is recommended
Immunoglobulins
Patients who may not have been immunized against Clostridium tetani products should receive tetanus immune globulin.
Tetanus immune globulins (Hyper-Tet)
Used for passive immunization of any person with a wound that may be contaminated with tetanus spores.
Adult
For prophylaxis: 250-500 U IM in opposite extremity to tetanus toxoid lesion
For clinical tetanus: 3,000-10,000 U IM
Pediatric
For prophylaxis: 250 U IM in the opposite extremity to tetanus toxoid
For clinical tetanus: 3,000-10,000 U IM
None reported
Because antibodies in globulin preparation may interfere with immune response to vaccination, do not administer within 3 mo of live-virus immune globulin administration; may be necessary to revaccinate persons who received immune globulin shortly after live-virus vaccination
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Persons with isolated IgA deficiency have potential for developing antibodies to IgA and could have anaphylactic reactions to subsequent administration of blood products that contain IgA; do not perform skin testing because intradermal injection of concentrated gamma globulin may cause localized area of inflammation and can be misinterpreted, causing the medication to be withheld from a patient not allergic to this material; true allergic responses to human gamma globulin given in prescribed IM manner are extremely rare; do not admix with other medications because usually incompatible
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| Differential Diagnoses & Workup: Fracture, Forearm |
 Treatment & Medication: Fracture, Forearm |
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References
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Further Reading
Keywords
forearm fracture, broken forearm, broken arm, arm fracture, limb fractures, limb fracture, fractured forearm, proximal forearm fractures, middle forearm fractures, forearm shaft fractures, distal shaft forearm fractures, osteoporosis
