Forearm Fractures in Emergency Medicine Treatment & Management
- Author: Toluwumi Jegede, MD; Chief Editor: Trevor John Mills, MD, MPH more...
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 the 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 the injury. Administer antibiotics and tetanus immunization, as indicated.
Immediate fracture reduction is indicated when any of the following exists:
Tenting of the skin
ED anesthesia/analgesia options include the following:
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.
The use of ketamine has been studied in pediatric patients undergoing forearm fracture reduction in the ED and has been found effective in 50% (ED50) and 95% (ED95) of healthy children aged 2 to 5, 6 to 11, or 12 to 17 years. ED50 was 0.7, 0.5, and 0.6 mg/kg and the estimated ED95 was 0.7, 0.7, and 0.8 mg/kg for the groups, respectively. The median total sedation time for the 3 age groups, respectively, was 25, 22.5, and 25 minutes if 1 dose of ketamine was administered and 35, 25, and 45 minutes if additional doses were administered.
In a study of periosteal nerve block with local anaesthesia in 42 patients with forearm fractures, 40 patients (95%) had successful fracture manipulation and did not require subsequent treatment. Of the 42 total patients, 40 underwent periosteal blocks in the emergency room or fracture clinic; 2 were already inpatients.
See the list below:
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.
Potential complications include the following:
Direct neurovascular injury
Physeal arrest if fracture involves the growth plate
Radioulnar synostosis after delayed treatment
Compartment syndrome - Associated with closed shaft fractures of the radius or ulna and with tight casts. It is less common in upper extremities than in lower extremities.
Loss of supination-pronation after a forearm fracture
Simon RR, Sherman SC, Koenigsknecht SJ. Forearm. Emergency Orthopedics: The Extremities. 5th ed. McGraw-Hill; 2007. 218-231.
Ryan LM. Forearm fractures in children and bone health. Curr Opin Endocrinol Diabetes Obes. 2010 Dec. 17(6):530-4. [Medline].
Orces CH, Martinez FJ. Epidemiology of fall related forearm and wrist fractures among adults treated in US hospital emergency departments. Inj Prev. 2011 Feb. 17(1):33-6. [Medline].
Benjamin H, Hang B. Common Acute Upper Extremity Injuries in Sports. Clin Ped Emerg Med. 8:15-30.
Zalavras C, Nikolopoulou G, Essin D, et al. Pediatric fractures during skateboarding, roller skating, and scooter riding. Am J Sports Med. 2005 Apr. 33(4):568-73. [Medline].
Naranje SM, Erali RA, Warner WC Jr, Sawyer JR, Kelly DM. Epidemiology of Pediatric Fractures Presenting to Emergency Departments in the United States. J Pediatr Orthop. 2016 Jun. 36 (4):e45-8. [Medline].
Gustilo RB, Mendoza RM, Williams DN. Problems in the management of type III (severe) open fractures: a new classification of type III open fractures. J Trauma. 1984 Aug. 24(8):742-6. [Medline].
Zalavras CG, Patzakis MJ, Holtom PD, et al. Management of open fractures. Infect Dis Clin North Am. 2005 Dec. 19(4):915-29. [Medline].
Gebuhr P, Holmich P, Orsnes T, et al. Isolated ulnar shaft fractures. Comparison of treatment by a functional brace and long-arm cast. J Bone Joint Surg Br. 1992 Sep. 74(5):757-9. [Medline].
Cai XZ, Yan SG, Giddins G. A systematic review of the non-operative treatment of nightstick fractures of the ulna. Bone Joint J. 2013 Jul. 95-B(7):952-9. [Medline].
Ramski DE, Hennrikus WP, Bae DS, Baldwin KD, Patel NM, Waters PM, et al. Pediatric Monteggia Fractures: A Multicenter Examination of Treatment Strategy and Early Clinical and Radiographic Results. J Pediatr Orthop. 2014 Jun 26. [Medline].
Betham C, Harvey M, Cave G. Manipulation of simple paediatric forearm fractures: a time-based comparison of emergency department sedation with theatre-based anaesthesia. N Z Med J. 2011 Oct 14. 124(1344):46-53. [Medline].
Chinta SS, Schrock CR, McAllister JD, Jaffe DM, Liu J, Kennedy RM. Rapid administration technique of ketamine for pediatric forearm fracture reduction: a dose-finding study. Ann Emerg Med. 2015 Jun. 65 (6):640-648.e2. [Medline].
Tageldin ME, Alrashid M, Khoriati AA, Gadikoppula S, Atkinson HD. Periosteal nerve blocks for distal radius and ulna fracture manipulation--the technique and early results. J Orthop Surg Res. 2015 Sep 2. 10:134. [Medline].
[Guideline] American Academy of Orthopaedic Surgeons clinical practice guideline on the treatment of distal radius fractures. National Guideline Clearinghouse. Available at http://www.guideline.gov/content.aspx?id=15486&search=distal+and+radius+and+ulna. 2009 Dec 5; Accessed: May 9, 2016.
Laidman J. Ibuprofen Better Option for Kids with Fracture. Medscape Medical News. Available at http://www.medscape.com/viewarticle/833895. Accessed: November 1, 2014.
Poonai N, Bhullar G, Lin K, Papini A, Mainprize D, Howard J, et al. Oral administration of morphine versus ibuprofen to manage postfracture pain in children: a randomized trial. CMAJ. 2014 Oct 27. [Medline].
Anderson LD, Meyer FN, Lippincott JB. Fractures of the shafts of the radius and ulna. Rockwood and Green's Fractures in Adults. 3rd ed. Publishers: Lippincott-Raven; 1991. 679-737.
Carson S, Woolridge D, Colletti J, et al. Pediatric Upper Extremity Injuries. Ped Clin North Am. 2006. 53:41-67.
Cheng JC, Shen WY. Limb fracture pattern in different pediatric age groups: a study of 3,350 children. J Orthop Trauma. 1993. 7(1):15-22. [Medline].
Cramer KE, Glasson S, Mencio G, et al. Reduction of forearm fractures in children using axillary block anesthesia. J Orthop Trauma. 1995. 9(5):407-10. [Medline].
Eastell R. Forearm fracture. Bone. 1996 Mar. 18(3 Suppl):203S-207S. [Medline].
Gleeson AP, Beattie TF. Monteggia fracture-dislocation in children. J Accid Emerg Med. 1994 Sep. 11(3):192-4. [Medline].
Gregory PR, Sullivan JA. Nitrous oxide compared with intravenous regional anesthesia in pediatric forearm fracture manipulation. J Pediatr Orthop. 1996 Mar-Apr. 16(2):187-91. [Medline].
Handoll HH, Madhok R. Closed reduction methods for treating distal radial fractures in adults. Cochrane Database Syst Rev. 2003. 4.
Handoll HH, Madhok R. Surgical interventions for treating distal radial fractures in adults. Cochrane Database Syst Rev. 2003. 4.
Handoll HH, Pearce PK. Interventions for isolated diaphyseal fractures of the ulna in adults. Cochrane Database Syst Rev. 2004. CD000523. [Medline].
Kay S, Smith C, Oppenheim WL. Both-bone midshaft forearm fractures in children. J Pediatr Orthop. 1986 May-Jun. 6(3):306-10. [Medline].
Kling J. Most Splints Misapplied in Children. Medscape Medical News. Oct 12 2014. Available at http://www.medscape.com/viewarticle/833122. Accessed: Oct 14 2014.
Macule Beneyto F, Arandes Renu JM, Ferreres Claramunt A, et al. Treatment of Galeazzi fracture-dislocations. J Trauma. 1994 Mar. 36(3):352-5. [Medline].
Metz VM, Gilula LA. Imaging techniques for distal radius fractures and related injuries. Orthop Clin North Am. 1993 Apr. 24(2):217-28. [Medline].
Morgan WJ, Breen TF. Complex fractures of the forearm. Hand Clin. 1994 Aug. 10(3):375-90. [Medline].
Newton EJ, Love J. Emergency department management of selected orthopedic injuries. Emerg Med Clin North Am. 2007 Aug. 25(3):763-93, ix-x. [Medline].
Proust AF, Bredenkamp JH, Uehara DT. Injuries to the elbow and forearm. Tintinalli JE, ed. Emergency Medicine: A Comprehensive Study Guide. 6th ed. McGraw Hill Text: 2004. 1690-1694.
Singletary EM. Volar dislocation of the distal radioulnar joint. Ann Emerg Med. 1994 Apr. 23(4):881-3. [Medline].
Younger AS, Tredwell SJ, Mackenzie WG, et al. Accurate prediction of outcome after pediatric forearm fracture. J Pediatr Orthop. 1994 Mar-Apr. 14(2):200-6. [Medline].
Zautcke JL. Forearm Injuries. Hart RG, Rittenberry TJ, eds. Handbook of Orthopaedic Emergencies. Lippincott Williams & Wilkins Publishers: 1999. 222-232.