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Pathological fracture - forearm — Clinical Guidelines

Overview

Forearm fractures, particularly in children, often require reduction procedures to restore alignment. Pathological fractures in adults may complicate management due to underlying bone pathology.

Diagnosis

Clinical Presentation: Pain, swelling, deformity, and limited range of motion 1 3.

Imaging: X-rays essential for fracture pattern identification (e.g., buckle, greenstick, bowing) 4 12.

Grading: Fracture type (e.g., Salter-Harris classification in pediatrics) guides management 3.

Management

Pain Management:

- Ketamine: Procedural sedation with ketamine for effective analgesia (dose and duration vary by age) 1 9. - Regional Anesthesia: Bier block and infraclavicular blocks as alternatives to procedural sedation 1 6 8. - Conscious Sedation: Nitrous oxide for less invasive sedation 11.

Reduction Techniques:

- Procedural Sedation: Commonly used for closed reduction 1 11. - General Anesthesia: For complex fractures requiring operating room settings 10. - Mini-C-arm Fluoroscopy: Enhances anatomic reduction and reduces radiation exposure 12.

Post-Reduction Imaging: Fluoroscopy vs. POCUS for assessing reduction adequacy 4.

Special Populations

Pediatrics:

- Regional Anesthesia: Preferred over procedural sedation due to safety profile and shorter recovery 2 6 8. - Bier Block: Effective and reduces length of stay 6. - Simulation Training: Increases comfort and utilization of Bier block techniques 8.

Elderly: Pathological fractures require careful assessment of underlying conditions affecting bone health 14.

Key Recommendations

Use Regional Anesthesia (e.g., Bier block) for pediatric forearm fracture reductions to enhance safety and reduce recovery time (Evidence: Strong 2 6 8).

Employ mini-C-arm fluoroscopy for post-reduction imaging to optimize fracture alignment and minimize radiation exposure (Evidence: Moderate 12).

Consider ketamine for procedural sedation in pediatric patients, optimizing dose based on age-specific efficacy studies (Evidence: Moderate 1 9).

Pediatric Emergency Physicians can achieve satisfactory reduction outcomes comparable to orthopedic surgeons with appropriate training and mentoring programs (Evidence: Moderate 5 7).

References

1 Sarcan E, Erdem AB, Uysal ŞB, Duman E, Cebeci Z, Arık E. Pain management with ketamine procedural sedation and infraclavicular block for forearm fracture in the emergency department. The American journal of emergency medicine 2025. link 2 Sulton CD, Fletcher N, Murphy J, Gillespie S, Burger RK. Regional Anesthesia as an Alternative to Procedural Sedation for Forearm Fracture Reductions in the Pediatric Emergency Department. Pediatric emergency care 2024. link 3 Selvakumaran G, Williams N. Buckled, bent or broken? A guide to paediatric forearm fractures. Australian journal of general practice 2020. link 4 Auten JD, Naheedy JH, Hurst ND, Pennock AT, Hollenbach KA, Kanegaye JT. Comparison of pediatric post-reduction fluoroscopic- and ultrasound forearm fracture images. The American journal of emergency medicine 2019. link 5 Hurt TL, Whitesell R, Mou J, Pflugeisen B. Does Mentoring by Orthopedic Surgeons Improve Forearm Fracture Reduction Outcomes by Pediatric Emergency Physicians? Evaluation of a Process Improvement Intervention Program. The Journal of emergency medicine 2019. link 6 Fauteux-Lamarre E, Burstein B, Cheng A, Bretholz A. Reduced Length of Stay and Adverse Events Using Bier Block for Forearm Fracture Reduction in the Pediatric Emergency Department. Pediatric emergency care 2019. link 7 Milner D, Krause E, Hamre K, Flood A. Outcome of Pediatric Forearm Fracture Reductions Performed by Pediatric Emergency Medicine Providers Compared With Reductions Performed by Orthopedic Surgeons: A Retrospective Cohort Study. Pediatric emergency care 2018. link 8 Burstein B, Fauteux-Lamarre E, Cheng A, Chalut D, Bretholz A. Simulation and Web-based learning increases utilization of Bier block for forearm fracture reduction in the pediatric emergency department. CJEM 2017. link 9 Chinta SS, Schrock CR, McAllister JD, Jaffe DM, Liu J, Kennedy RM. Rapid administration technique of ketamine for pediatric forearm fracture reduction: a dose-finding study. Annals of emergency medicine 2015. link 10 Yamamoto LG. Reduction of bowing forearm fractures in the ED under propofol sedation. The American journal of emergency medicine 2012. link 11 McKenna P, Leonard M, Connolly P, Boran S, McCormack D. A comparison of pediatric forearm fracture reduction between conscious sedation and general anesthesia. Journal of orthopaedic trauma 2012. link 12 Lee MC, Stone NE, Ritting AW, Silverstein EA, Pierz KA, Johnson DA et al.. Mini-C-arm fluoroscopy for emergency-department reduction of pediatric forearm fractures. The Journal of bone and joint surgery. American volume 2011. link 13 Constantine E, Steele DW, Eberson C, Boutis K, Amanullah S, Linakis JG. The use of local anesthetic techniques for closed forearm fracture reduction in children: a survey of academic pediatric emergency departments. Pediatric emergency care 2007. link 14 Shenoy RM. Biplanar exposure of the radius and ulna through a single incision. The Journal of bone and joint surgery. British volume 1995. link

Pathological fracture - forearm