Forearm Fractures in Emergency Medicine Treatment & Management

Updated: May 09, 2016
  • Author: Toluwumi Jegede, MD; Chief Editor: Trevor John Mills, MD, MPH  more...
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Treatment

Prehospital Care

Stabilize the arm to prevent or limit neurovascular injury from sharp bone fragments.

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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:

  • Neurovascular compromise

  • Severe displacement

  • Tenting of the skin

ED anesthesia/analgesia options [12] 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. [13]

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 blocks in the emergency room or fracture clinic; 2 were already inpatients. [14]

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Consultations

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.

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Complications

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

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