Emergency Department Care
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:
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Neurovascular compromise
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Severe displacement
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Tenting of the skin
ED anesthesia/analgesia options [23] include the following:
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Axillary block provides complete anesthesia and muscle relaxation but carries the risk of arterial or nerve injury.
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Hematoma block provides anesthesia and muscle relaxation but carries the risk of osteomyelitis.
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Intravenous regional anesthesia (Bier block) provides anesthesia and muscle relaxation but carries the risk of lidocaine toxicity.
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Conscious sedation provides effective anesthesia, muscle relaxation, and amnesia. It carries the risk of respiratory depression and requires increased nursing time.
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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.
Complications
Potential complications of forearm fracture and its management include the following:
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Direct neurovascular injury
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Physeal arrest if fracture involves the growth plate
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Radioulnar synostosis after delayed treatment
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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
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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]
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Fractures of the radius and ulna with dorsal angulation of distal fragments.
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Torus fracture of the radius.
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Torus fracture of the radius.
