Rosen & Barkin's 5-Minute Emergency Medicine Consult (276 page)

Manage coexisting trauma as indicated.

• Airway, breathing, and circulation management
  
• Assess for neurovascular compromise distal to fracture site.
  
• Dislocations must be reduced as quickly as possible with assessment of neurovascular status before and after procedure:
  
  • Procedural sedation usually required
    
• Immobilize, ice, and elevate in a bulky splint:
  
  • Application of circumferential cast should be delayed until swelling subsides.
    
• Crutches
  
• Pain management:
  
  • If large amount of swelling and pain with toe movement, suspect compartment syndrome.
    
  • Ultrasound-guided regional anesthesia may be used for reduction
    
• Orthopedic consult indicated early for displaced fractures:
  
  • Many injuries require repair within 6 hr of injury to prevent delay of open reduction with internal fixation for 6–10 days owing to swelling.
    

• Cefazolin: 1 g IV/IM (peds: 25 mg/kg IV/IM)
  
• Diprivan: 40 mg IV q10s until sedation
  
• Etomidate: 0.1–0.2 mg/kg IV
  
• Fentanyl: 50–250 μg IV titrated (peds: 2 μg/kg IV)
  
• Hydromorphone 0.5–2 mg IV q2h (peds: 0.15 mg/kg IV q4–6h)
  
• Ibuprofen: 800 mg PO (peds: 10 mg/kg PO)
  
• Meperidine: 25–100 mg IV/IM titrated (peds: 1–1.75 mg/kg IV/IM)
  
• Methohexital: 1–1.5 mg/kg IV
  
• Morphine: 2–10 mg IV/IM titrated (peds: 0.1 mg/kg IV)
  

FOLLOW-UP

• Open fracture
  
• Evidence of compartment syndrome or neurovascular injury
  
• Open reduction internal fixation required immediately
  

Most patients with metatarsal fractures can be discharged with orthopedic follow-up.

All open fractures, as well as all midfoot/Lisfranc injuries and displaced fractures that are not successfully reduced, should be seen in ED by an orthopedic specialist.

• Banarjee R, Nickishch F, Easley ME, et al. Foot fractures. In: Browner, ed.
  Skeletal Trauma
  , 4th ed., Vol. 2. Philadelphia, PA: Saunders; 2008, Chapter 61.
  
• Green NE, Swiontkowski M.
  Skeletal Trauma in Children: Foot Fractures
  , 4th ed. Philadelphia, PA: Saunders; 2008, Chapter 16.
  
• Harrast MA, Colonno D. Stress fractures in runners.
  Clin Sports Med.
  2010;29(3):399–416.
  
• Ishikawa SN. Fractures and dislocations of the foot. In:
  Canale ST & Beaty JH; eds. Campbell’s Operative Orthopedics
  . 12th ed. Mosby St. Louis, MO; 2012, Chapter 88.
  
• Khan W, Oragui E, Akagha E. Common fractures and injuries of the ankle and foot: Functional anatomy, imaging, classification and management.
  J Perioper Pract.
  2010;20(7):249–258.
  

CODES

• 825.20 Closed fracture of unspecified bone(s) of foot [except toes]
  
• 825.25 Closed fracture of metatarsal bone(s)
  
• 825.29 Other closed fracture of tarsal and metatarsal bones
  

BASICS

• 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 dislocation
      
  • Monteggia
    fracture:
    
    • Proximal ulnar fracture with dislocation of radial head
      
• 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
      
  • Smith
    fracture:
    
    • Hyperflexion fracture of distal radius
      
    • Distal fragment displaced volarly
      
  • Barton
    fracture:
    
    • Intra-articular fracture of dorsal rim of distal radius
      
    • Often associated with dislocation of carpal bones
      
  • Hutchinson
    fracture:
    
    • Intra-articular fracture of radial styloid
      

• Shaft fractures:
  
  • Torus
    fracture:
    
    • Compression (buckling) of cortex on 1 or both sides
      
  • Greenstick
    fracture:
    
    • Distraction of 1 side of cortex with opposite side intact
      
  • Plastic deformity:
    
    • Bowing of radius or ulna without apparent disruption of cortex
      
    • Multiple microfractures
      
• Distal fractures:
  
  • Salter–Harris
    type fractures (see Salter–Harris classification)
    

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

DIAGNOSIS

• Deformity
  
• Pain, edema, erythema
  

• 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 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
  

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

Preoperative labs as warranted

Some intra-articular fractures may require CT imaging.

Compartment pressures should be measured for suspected compartment syndrome.

• Upper extremity muscle, ligamentous injury
  
• Elbow or wrist dislocations, including pediatric nursemaid’s 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

• 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.
    

• Shaft fractures, nondisplaced:
  
  • Long-arm splint
    
  • Orthopedic referral
    
• Shaft fractures, displaced:
  
  • Orthopedic consultation
    
  • Often require open reduction, internal fixation
    
• Distal fractures, nondisplaced:
  
  • Forearm sugar-tong or AP splint
    
  • Orthopedic referral
    
• Distal fractures:
  Colles/Smith:
  
  • Simple, noncomminuted, extra-articular Colles and Smith fractures may be reduced in ED:
    
    • Splint (long-arm sugar-tong splint)
      
    • Sling
      
    • Referred to orthopedics
      
  • Complicated Colles and Smith fractures require orthopedic consultation.
    
• Distal fractures:
  Barton/Hutchinson:
  
  • Uncomplicated Barton and Hutchinson fractures
    
    • Splint (AP or sugar-tong splint)
      
    • Place in sling
      
    • Referred to orthopedics
      
  • Complicated fractures require orthopedic consultation.
    
• Open fractures:
  
  • Cover with sterile dressings.
    
  • IM/IV antibiotics
    
  • Tetanus immunization (if indicated)
    
  • Splint
    
  • Immediate orthopedic consultation
    
• Forearm fractures associated with compartment syndrome or neurovascular compromise require immediate orthopedic consultation.