Forearm Fracture Management in the ED

Forearm fractures are among the most frequently encountered orthopedic injuries in children. Maintenance of satisfactory alignment can be problematic, and postreduction displacement with resultant malunion can occur.[10]

Because of osteoporosis, postmenopausal women have a higher rate of forearm fracture than other adults. When the mechanism of injury seems trivial, suspect a pathologic fracture associated with a cyst or a tumor. Forearm fractures in older persons are associated with increased risk of future vertebral and hip fractures. Forearm fractures are less common among black individuals because of a lower incidence of osteoporosis.

The National Electronic Injury Surveillance System database showed that among patients from birth to 19 years of age, fracture of the forearm was found to be the most common type of fracture, accounting for 17.8% of all fractures in the entire study population. Finger and wrist fractures were the second and third most common.[11]

In infants and toddlers, forearm fractures have no sex predilection. In children older than 2 years, forearm fractures are more common in boys than in girls. In older persons, fractures are more common in women than in men.

Open fractures of the forearm from gunshot wounds are serious injuries that carry high rates of nonunion and infection. Fractures with significant bone defects are at increased risk of nonunion and should be treated with stable fixation and proper soft tissue handling. Ulna fractures are at particularly high risk for deep infection and septic nonunion and should be treated aggressively. Forearm fractures from gunshots should be followed until union to identify long-term complications.[12]

For excellent patient education resources, visit the First Aid and Injuries Center. Also see the patient education article Broken Arm.

Patients usually have localized pain, tenderness, and swelling at the fracture site. Fractures are classified as open or closed. Consider any puncture or break in the skin over a fracture site evidence of an open fracture unless proven otherwise. Infection is commonly seen with open fractures and warrants emergent orthopedic evaluation. The incidence of open forearm fractures is second only to that of the tibia.

History is usually consistent with a direct blow to the forearm or a fall directly onto the forearm or outstretched hand. Understanding the mechanism of injury helps direct the physical examination to detect injuries.

The Gustilo open fracture classification system[13, 14]  has significant interuser variability; the extent of the wound often cannot be determined until intraoperative exploration is performed. Forearm fractures are classified as follows[15] :

• Type I: Puncture wound less than 1 cm; minimal contamination; minimal soft tissue damage

• Type II: Laceration greater than 1 cm but less than 10 cm; moderate soft tissue damage; adequate bone coverage

• Type IIIA: Laceration greater than 10 cm; extensive soft tissue damage; massive contamination; adequate bone coverage

• Type IIIB: Laceration greater than 10 cm; extensive soft tissue damage; massive contamination; periosteal stripping and bone exposure

• Type IIIC: Arterial injury requiring repair

Perform a neurologic examination. Evaluate sensory function by 2-point discrimination. Assess motor function by having the patient make the following maneuvers: "OK" sign tests the median nerve, extending the fingers or wrist against resistance tests the radial nerve, and separating the fingers against resistance tests the ulnar nerve.

Tendons or muscle bellies entrapped in fracture fragments may account for unusual functional deficits.

Perform a vascular examination. Check capillary refill and radial pulse, and perform the Allen test.

Examine the wrist and elbow for tenderness and range of motion. Palpate the wrist to evaluate for ulnar styloid fracture, dorsal prominence of the ulna, or wrist pain with rotation.Tenderness or prominence of the radial head may be the only physical finding in patients with reduced Monteggia lesion or radial head fracture.

General radiography principles

Anteroposterior and lateral views of the wrist, forearm, and elbow are required when forearm fracture is suspected from clinical findings.

Forearm radiographs, which include distal joints, are inadequate for absolutely excluding associated wrist and elbow injuries, as diagnosis of radioulnar dislocation requires the x-ray beam to be centered at the joint.

In addition to diagnosis and follow-up, radiologic imaging plays a decisive role in the treatment of distal forearm fractures. Computed tomography (CT) and direct CT arthrography have become important tools in treatment of intra-articular distal radius fractures. Direct CT arthrography allows not only analysis of the fracture pattern, but also detection of accompanying injuries of the carpus, especially the scapholunate ligament and the ulnocarpal complex. Plain radiographs should also be analyzed for accompanying injuries.[3]

With forearm fracture, painful limitations in range of motion, especially of pronation and supination, are often due to underdiagnosed torsional deformity; new methods can make these torsional differences visible and quantifiable through the use of sectional imaging. In the presence of torsional deformities, radiologic measurements can help one decide if an operation is needed or not. Decisions must be made together with the patient by taking clinical and radiologic results into account.[8]

Ultrasound-guided infraclavicular block is a safe and effective method in the management of pain during closed reduction of forearm fracture in pediatric patients in the ED. It can be used safely in emergency rooms and has a high level of both parental and operator satisfaction.[16]

Radiographs taken at 2-week follow-up have resulted in a change in treatment in 3.1% of cases. Given the low cost and the minimal risk of radiographs of an extremity, it is believed that the benefits outweigh the costs of routine radiographs taken 2 weeks after surgical treatment of distal forearm fracture.[17]

Nightstick fracture

Defined as an isolated midshaft ulnar fracture, usually resulting from the forearm being held in protection across the face, nightstick fracture can also occur with excessive supination or pronation. This type of fracture requires orthopedic referral; the forearm can be immobilized with a long-arm splint with 90º of elbow flexion and with the hand in a neutral position. Some advocate that, after 1 week, the splint or cast should be replaced by a prefabricated functional brace, which allows better wrist mobility and return to function.[18] Open reduction internal fixation (ORIF) becomes necessary when displacement greater than 5 mm or angulation greater than 10º persists.

A systematic review of trials and observational studies that assessed the outcomes of nightstick fracture after above- or below-elbow immobilization, bracing, and early mobilization found that early mobilization was associated with the shortest radiologic time to union (mean, 8.0 wk) and the lowest mean rate of nonunion (0.6%). Fractures that were treated with above-elbow immobilization, below-elbow immobilization, or bracing had longer mean radiologic times to union (9.2 wk, 9.2 wk, and 8.7 wk, respectively) and higher mean rates of nonunion (3.8%, 2.1%, and 0.8%, respectively).[19]

Monteggia fracture

Monteggia fracture is defined as a fracture of the ulna (usually the proximal one third) with dislocation of the radial head. Anterior radial head dislocation is most common (60%), yet medial, lateral, and posterior dislocations also occur. Isolated proximal ulnar fractures are rare. Always suspect a Monteggia fracture/dislocation, and closely examine the radial head for dislocation or other evidence of injury.

Radial head dislocation can be missed when radiographs are misinterpreted, falsely negative, or inadequate. It also may go unrecognized when the dislocation reduces spontaneously prior to imaging. A line drawn through the radial shaft and head must align with the capitellum in all views to exclude dislocation.

Immobilize with a long-arm splint (with elbow flexed 90° and forearm neutral). Children may be treated by reduction and casting; adults require admission for ORIF.

One study assessed the efficacy of the following treatment strategy for Monteggia fracture based on the ulnar fracture pattern: closed reduction for plastic/greenstick fractures; intramedullary pin fixation for transverse/short oblique fractures; and ORIF for long oblique/comminuted fractures. Results show that none of the 57 patients treated according to this strategy experienced failure. However, 6 of 32 patients who were treated less rigorously demonstrated recurrent radiocapitellar instability (3 patients), loss of ulnar fracture reduction requiring revision surgery (2 patients), or both events (1 patient). All treatment failures occurred in complete fractures treated nonoperatively.[20]

Galeazzi fracture

Galeazzi fracture is defined as a fracture of the distal one third of the radius, with dislocation of the distal radioulnar joint (DRUJ). It is also known as a reverse Monteggia fracture. Galeazzi fracture is 3 times more common than the Monteggia lesion. This fracture is considered highly unstable and comes under the category of fracture of necessity because it necessitates surgical treatment.[1]  Disruption of the DRUJ when overlooked results in a higher rate of morbidity.

Shortening of the radius by 5 mm, fracture of the base of the ulnar styloid, widening of the DRUJ space by 2 mm, and subluxation of the DRUJ are all associated with DRUJ pathology. Obtaining comparison views of the uninjured wrist may be helpful. A 10-20° rotation from normal radiographic position may give false-negative or false-positive readings for DRUJ dislocation. Immobilize with a long-arm splint (with elbow flexed 90° and forearm pronated). Treatment requires admission for open reduction internal fixation (ORIF).

Concomitant radius and ulna fractures

Concomitant fractures usually result from a significant force applied directly to the forearm, or from major multisystem trauma. Swelling and deformity indicate the diagnosis, and radiographic confirmation is usually straightforward. Compartment syndrome is a potential complication because of the degree of tissue injury and swelling involved. Treatment usually requires admission for an urgent ORIF, although in children younger than 10 years, if reduced to less than 10° of angulation, these fractures may be treated by casting alone.

(See the image below.)

Essex-Lopresti fracture

Essex-Lopresti fracture is defined as a fracture of the radial head and dislocation of the DRUJ, with partial or complete disruption of the radioulnar interosseous membrane.

Acute Essex-Lopresti injury is a rare and disabling condition of longitudinal instability of the forearm. When diagnosed early, patients report better outcomes with higher functional recovery.[21]

Torus (greenstick) fracture

Torus fracture is the most common childhood fracture; it accounts for for 500,000 emergency attendances per year, according to a study in the United Kingdom.[22]

Torus fracture occurs in children with only a moderate degree of trauma and can be managed with a long-arm cast for 4-6 weeks when angulation is less than 10°. All cases require orthopedic referral.

(See the images below.)

The arm should be stabilized to prevent or limit neurovascular injury from sharp bone fragments.

Immobilize the forearm and the 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 to evaluate for associated dislocation.

Obtain computed tomography (CT) and direct CT arthrography images to explore the fracture pattern and to detect accompanying injuries.[3]

Treat the injury expeditiously. Provide adequate analgesia/anesthesia.

Use ultrasound-guided infraclavicular block to manage pain during closed reduction of forearm fracture in pediatric patients in the ED. This method minimizes serious respiratory and cardiac complications and can be used safely in the emergency room.[16]

Perform emergent reduction, if necessary. Bone ends may shift, resulting in 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:

• Neurovascular compromise

• Severe displacement

• Tenting of the skin

ED anesthesia/analgesia options[23]  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.

• Ultrasound-guided infraclavicular block effectively manages pain while minimizing respiratory and cardiac complications.[16]

Insufficient evidence exists to support a specific management technique for isolated fractures of the ulna.

Evidence indicates that distal radius fractures may have better outcomes with external fixation or pinning than with conservative, nonsurgical management.

Refer the patient to an orthopedist for open fractures, operative fractures, or dislocations, and arrange close follow-up care. Radiographs should be obtained at 2-week follow-up to evaluate healing and to determine whether a change in treatment is needed.[17]

Open fractures of the forearm from gunshot wounds are serious injuries that carry high rates of nonunion and infection. Fractures with significant bone defects are at increased risk of nonunion and should be treated with stable fixation and proper soft tissue handling. Ulna fractures are at particularly high risk for deep infection and septic nonunion and should be treated aggressively. Forearm fractures from gunshots should be followed until union to identify long-term complications.[12]

Use of ketamine has been studied in pediatric patients undergoing forearm fracture reduction in the ED and has been found to be effective in 50% (ED50) and 95% (ED95) of healthy children aged 2-5, 6-11, or 12-17 years. ED50 was 0.7, 0.5, and 0.6 mg/kg, and estimated ED95 was 0.7, 0.7, and 0.8 mg/kg for these 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.[24]

In a study of periosteal nerve block with local anesthesia 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 block in the emergency room or fracture clinic; 2 were already inpatients.[25]

Consult an orthopedist for open fractures, operative fractures, or dislocations, and arrange close follow-up care. Fracture reductions typically are referred to an orthopedist unless evidence of neurovascular compromise is noted.

Potential complications of forearm fracture and its management 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 or limited range of motion, especially of pronation and supination, often due to underdiagnosed torsional deformity; torsional differences are now visible and quantifiable through sectional imaging methods[8]

The American Academy of Orthopaedic Surgeons clinical practice guidelines on the treatment of distal radius fractures include the following[26] :

• Rigid immobilization is preferred to use of removable splints when nonoperative treatment is provided for management of a displaced distal radius fracture.

• Use of removable splints is an option when a minimally displaced distal radius fracture is treated.

• Consider operative fixation, as opposed to cast fixation, for a forearm fracture with post-reduction radial shortening >3 mm, dorsal tilt >10 degrees, or intra-articular displacement or step-off >2 mm.

• Nonoperative treatment of a distal radius fracture should be followed by ongoing radiographic evaluation for 3 weeks and at cessation of immobilization.

• All patients with distal radius fracture should receive a post-reduction true lateral x-ray of the carpus for assessment of distal radial ulnar joint (DRUJ) alignment.

Generally, use NSAIDs and analgesics to treat fractures. In addition, administer proper antibiotics and tetanus prophylaxis for open fractures. According to a study involving 134 children treated for fracture in the ED, ibuprofen is just as effective as morphine for pain control. Children in the study received either 4 doses of normal-release morphine or 4 doses of ibuprofen every 6 hours, as needed, for 24 hours following discharge. No significant differences between groups were seen in pain scores after any of the 4 doses. Adverse effects of morphine included nausea, vomiting, and drowsiness. The percentage of patients in the morphine group experiencing adverse events was 56.1%, compared with 30.9% in the ibuprofen group (P< 0.01).[27, 28]

Class Summary

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 drug of choice (DOC) for initial therapy. Other options include flurbiprofen, ketoprofen, and naproxen.

Ibuprofen (Ibuprin, Advil, Motrin)

Selected as usual 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.

Ketoprofen (Oruvail, Orudis, Actron)

Used for relief of mild to moderately severe pain and inflammation. Administer small dosages initially to patients with small bodies, to older persons, and to those with renal or liver disease. Doses higher than 75 mg do not increase therapeutic effects. Administer high doses with caution and closely observe.

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.

Flurbiprofen (Ansaid, Ocufen)

Has analgesic, antipyretic, and anti-inflammatory effects. May inhibit cyclooxygenase enzyme, inhibiting prostaglandin biosynthesis.

Class Summary

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.

Hydrocodone bitartrate and acetaminophen (Vicodin ES)

Drug combination indicated for relief of moderately severe to severe pain.

Oxycodone and acetaminophen (Percocet)

Drug combination indicated for relief of moderately severe to severe pain. DOC for aspirin-hypersensitive patients.

Class Summary

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.

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.

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. Dose may need to be adjusted for patients with renal impairment.

Class Summary

This agent is used for tetanus immunization. A booster injection in previously immunized individuals is recommended to prevent this potentially lethal syndrome.

Tetanus toxoid adsorbed or fluid

Used to induce active immunity against tetanus in selected patients. Tetanus and diphtheria toxoids are immunizing AOC for most adults and children >7 years. Booster doses needed to maintain tetanus immunity throughout life. Pregnant patients should receive only tetanus toxoid, not a diphtheria antigen-containing product. In children and adults, may be administered into deltoid or mid-lateral thigh muscles. In infants, preferred site of administration is mid-thigh laterally.

Class Summary

Patients who may not have been immunized against Clostridium tetani products should receive tetanus immune globulin.

Tetanus immune globulin (TIG)

Used for passive immunization of any person with a wound that may be contaminated with tetanus spores.