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Forearm Fracture, Shaft/Distal, Emergency Medicine

Basics

Description

- Distal fractures include extension, flexion, and intra-articular classifications: - Colles fracture: - Hyperextension fracture of distal radius - Distal fragment displaced dorsally - Radial deviation - Often involves ulnar styloid and distal radioulnar joint

  • Forearm shaft fractures (single or paired) are often displaced by contraction of arm muscles; sometimes associated with concurrent dislocations:Galeazzi fracture:Distal radius fracture with distal radioulnar dislocationMonteggia fracture:Proximal ulnar fracture with dislocation of radial head
  • Distal fractures include extension, flexion, and intra-articular classifications:Colles fracture:Hyperextension fracture of distal radiusDistal fragment displaced dorsallyRadial deviationOften involves ulnar styloid and distal radioulnar jointSmith fracture:Hyperflexion fracture of distal radiusDistal fragment displaced volarlyBarton fracture:Intra-articular fracture of dorsal rim of distal radiusOften associated with dislocation of carpal bonesHutchinson fracture:Intra-articular fracture of radial styloid
  • Shaft fractures:Torus fracture:Compression (buckling) of cortex on 1 or both sidesGreenstick fracture:Distraction of 1 side of cortex with opposite side intactPlastic deformity:Bowing of radius or ulna without apparent disruption of cortexMultiple microfractures
  • Distal fractures:Salter-Harris type fractures (see Salter-Harris classification)

Etiology

  • Direct blow to forearm
  • Longitudinal compression load:Fall on outstretched hand (FOOSH)Horizontal force
  • Excessive pronation, supination, hyperextension, or hyperflexion

Diagnosis

Signs and Symptoms

  • Deformity
  • Pain, edema, erythema

History

  • Associated events and concurrent injuries
  • Past history of bone disease or old fractures
  • History of repetitive stress of forearm movement
  • Occupation
  • Hand dominance

Physical Exam

  • Physical exam with special attention to skin integrity, deformity, and neurovascular status
  • Forearm pain, crepitus, tenderness to palpation, deformity, shortening of forearm
  • Forearm edema, ecchymosis, elbow or wrist joint effusions
  • Abnormal mobility or loss of function at elbow/wrist/hand
  • Neurologic abnormalities
  • Vascular compromise

Impending compartment syndrome

Essential Workup

Suspected forearm fractures require anteroposterior (AP) and lateral radiographs, including joint above and joint below injury: Hand, wrist, and elbow.

Diagnosis Tests & Interpretation

Lab

Preoperative labs as warranted

Imaging

Some intra-articular fractures may require CT imaging.

Diagnostic Procedures/Surgery

Compartment pressures should be measured for suspected compartment syndrome.

Differential Diagnosis

  • Upper extremity muscle, ligamentous injury
  • Elbow or wrist dislocations, including pediatric nursemaids elbow
  • Forearm contusions, hematomas
  • Cellulitis, abscesses, soft tissue masses
  • Forearm osteogenic tumors
  • Osteomyelitis
  • Upper extremity vascular or neurologic injuries
  • Elbow or wrist arthritis, joint effusions
  • Pediatric growth plates, nutrient vessels may be mistaken for fractures

Treatment

Pre-Hospital

  • All suspected forearm fractures should be elevated, splinted, and immobilized, including elbow and wrist joints.
  • All open fractures should be wrapped with sterile dressing before immobilization:Do not reduce open fractures back under skin in the field.In patients with isolated extremity trauma, analgesia may be administered.

Ed Treatment/Procedures

  • Shaft fractures, nondisplaced:Long-arm splintOrthopedic referral
  • Shaft fractures, displaced:Orthopedic consultationOften require open reduction, internal fixation
  • Distal fractures, nondisplaced:Forearm sugar-tong or AP splintOrthopedic referral
  • Distal fractures: Colles/Smith:Simple, noncomminuted, extra-articular Colles and Smith fractures may be reduced in ED:Splint (long-arm sugar-tong splint)SlingReferred to orthopedicsComplicated Colles and Smith fractures require orthopedic consultation.
  • Distal fractures: Barton/Hutchinson:Uncomplicated Barton and Hutchinson fracturesSplint (AP or sugar-tong splint)Place in slingReferred to orthopedicsComplicated fractures require orthopedic consultation.
  • Open fractures:Cover with sterile dressings.IM/IV antibioticsTetanus immunization (if indicated)SplintImmediate orthopedic consultation
  • Forearm fractures associated with compartment syndrome or neurovascular compromise require immediate orthopedic consultation.
  • Torus and Greenstick fractures with <10 ° of angulation may be treated with long-arm splint, sling, and orthopedic referral.
  • Plastic deformities require orthopedic consultation:Some minimally displaced plastic deformities may be placed in long-arm splint and sling.
  • Salter-Harris type fractures require orthopedic consultation.

Medication

  • Acetaminophen: 325-1,000 mg PO q4h (peds: 10-15 mg/kg q4h PO)
  • Antibiotics:Open fractures require IM/IV antibiotics.Cefazolin: 1-2 g IM/IV or equivalent 1st-generation cephalosporin; if contaminated, add an aminoglycoside
  • Codeine: 15-60 mg PO/IM q4h (peds: >2 yr, 0.5-1 mg/kg q4h PO/IM)
  • Hydrocodone: 5-10 mg PO q4h
  • Ibuprofen: 200-800 mg q4-8h (peds: >6 mo, 5-10 mg/kg per dose q6h)
  • Morphine sulfate: 2-10 mg IV/IM; titrate to pain (peds: 0.1 mg/kg per dose IV/IM)
  • Tetanus: 0.5 mL IM every 10 yr

Follow-Up

Disposition

Admission Criteria

  • Open fractures
  • Fractures with compartment syndrome or neurovascular compromise
  • Fractures needing immediate operative management or general anesthesia for reduction
  • Suspected nonaccidental trauma

Discharge Criteria

  • Appropriate reduction and immobilization
  • Arranged orthopedic follow-up
  • Adequate pain control measures
  • Cast/splint care discharge instructions provided and understood by patient
  • Documentation of intact neurovascular function after ED treatment

Issues for Referral

All fractures (or suspected fractures) discharged from ED should be referred to orthopedic surgeon for close follow-up.

Followup Recommendations

All patients should be referred to an orthopedic surgeon or hand surgeon.

Pearls and Pitfalls

  • Missed 2nd fracture
  • Missed concurrent dislocation or subluxation
  • Impending compartment syndrome

Additional Reading

  • Black WS, Becker JA. Common forearm fractures in adults. Am Fam Physician. 2009;80(10):1096-1102.
  • Handoll HH, Pearce P. Interventions for isolated diaphyseal fractures of the ulna in adults. Cochrane Database Syst Rev. 2009;(3):CD000523.
  • Madhuri V, Dutt V, Gahukamble AD, et al. Conservative interventions for treating diaphyseal fractures of the forearm bones in children. Cochrane Database Syst Rev. 2013;4:CD008775.
  • Perron AD, Brady WJ. Evaluation and management of the high-risk orthopedic emergency. Emerg Med Clin North Am. 2003;21(1):159-204.

Codes

ICD9

  • 813.23 Closed fracture of shaft of radius with ulna
  • 813.44 Closed fracture of lower end of radius with ulna
  • 813.80 Closed fracture of unspecified part of forearm
  • 813.42 Other closed fractures of distal end of radius (alone)
  • 813.03 Closed Monteggias fracture
  • 813.13 Open Monteggia's fracture
  • 813.33 Open fracture of shaft of radius with ulna
  • 813.41 Closed Colles' fracture
  • 813.51 Open Colles' fracture
  • 813.52 Other open fractures of distal end of radius (alone)
  • 813.54 Open fracture of lower end of radius with ulna
  • 813.90 Open fracture of unspecified part of forearm

ICD10

  • S52.90XA Unsp fracture of unsp forearm, init for clos fx
  • S52.509A Unsp fracture of the lower end of unsp radius, init
  • S52.609A Unsp fracture of lower end of unsp ulna, init for clos fx
  • S52.379A Galeazzis fracture of unsp radius, init for clos fx
  • S52.209A Unsp fracture of shaft of unsp ulna, init for clos fx
  • S52.209B Unsp fx shaft of unsp ulna, init for opn fx type I/2
  • S52.279A Monteggia's fracture of unsp ulna, init for clos fx
  • S52.279B Monteggia's fracture of unsp ulna, init for opn fx type I/2
  • S52.309A Unsp fracture of shaft of unsp radius, init for clos fx
  • S52.309B Unsp fx shaft of unsp radius, init for opn fx type I/2
  • S52.379B Galeazzi's fracture of unsp radius, init for opn fx type I/2
  • S52.509B Unsp fx the lower end unsp radius, init for opn fx type I/2
  • S52.539A Colles' fracture of unsp radius, init for clos fx
  • S52.539B Colles' fracture of unsp radius, init for opn fx type I/2
  • S52.569A Barton's fracture of unsp radius, init for clos fx
  • S52.569B Barton's fracture of unsp radius, init for opn fx type I/2
  • S52.609B Unsp fx lower end of unsp ulna, init for opn fx type I/2
  • S52.90XB Unsp fracture of unsp forearm, init for opn fx type I/2

SNOMED

  • 91419009 Closed fracture of forearm (disorder)
  • 33192001 Closed fracture of lower end of radius AND ulna (disorder)
  • 208309008 Closed fracture radius and ulna, middle (disorder)
  • 208322000 Closed Galeazzi fracture (disorder)
  • 123971006 Colles fracture (disorder)
  • 123973009 Monteggia's fracture (disorder)
  • 208341002 Open Galeazzi fracture (disorder)
  • 54645004 Barton's fracture (disorder)
  • 88116004 Open fracture of lower end of radius AND ulna (disorder)
  • 91296001 Open fracture of forearm (disorder)