WORKUP	Section 5 of 11
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Imaging Studies:

• General radiography principles

• Anteroposterior and lateral views of 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.

• Nightstick fracture: Defined as an isolated midshaft ulnar fracture, these require orthopedic referral and can be immobilized with a long-arm splint. Open reduction and internal fixation (ORIF) becomes necessary when displacement greater than 5 mm or angulation greater than 10° persists.

• Monteggia fracture

• Defined as a fracture of the ulna (usually 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 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, while adults require admission for ORIF.

• Galeazzi fracture

• 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 Monteggia lesion.

• Disruption of DRUJ when overlooked results in a higher rate of morbidity.

• Shortening of the radius by 5 mm, fracture of ulnar styloid, widening of DRUJ space by 2 mm, or subluxation of DRUJ all are 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 an ORIF.

	TREATMENT	Section 6 of 11
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Prehospital Care: Stabilize arm to prevent or limit neurovascular injury from sharp bone fragments.

Emergency Department Care:

• Immobilize forearm and upper arm and provide effective analgesia unless 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 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 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 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

• Axillary block provides complete anesthesia and muscle relaxation but carries risk of arterial or nerve injury.

• Hematoma block provides anesthesia and muscle relaxation but carries risk of osteomyelitis.

• Intravenous regional anesthesia (Bier block) provides anesthesia and muscle relaxation but carries risk of lidocaine toxicity.

• Inhaled nitrous oxide sedation avoids need for intravenous access, though it has variable efficacy.

• Conscious sedation provides effective anesthesia, muscle relaxation, and amnesia. It carries the risk of respiratory depression and requires increased nursing time.

Consultations:

• Consult 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.

	MEDICATION	Section 7 of 11
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Drugs used to treat fractures are generally NSAIDs and analgesics. In addition, administer proper antibiotics and tetanus prophylaxis for open fractures.

	MISCELLANEOUS	Section 9 of 11
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Medical/Legal Pitfalls:

• Failure to suspect DRUJ pathology in face of isolated radial fracture (Galeazzi type)

• Failure to suspect radial head dislocation in face of isolated ulnar fracture (Monteggia type)

• Radial head dislocations usually can be reduced or closed early in presentation, but delayed diagnosis commonly requires open reduction.

• Lesions undiagnosed by the emergency physician are likely to be missed on outpatient follow-up visit.

• Spontaneous reduction during splinting and loss of physical findings of pain at the radial head by the time of follow-up contribute to delayed or missed diagnosis

• Failure to appreciate an open fracture (attributing wounds to a simple soft-tissue injury)

• Failure to recognize neurovascular injury

Special Concerns:

• Suspect child abuse when mechanism of injury is inconsistent with fracture type, especially in newborns and infants.

• Realize that lesser amounts of mechanical force may result in fracture, especially in postmenopausal women.