Overview
Fracture malunion of the forearm refers to improper healing of a forearm fracture, leading to deformity, pain, and functional impairment despite initial reduction attempts 1.Diagnosis
Radiographic evaluation essential: Antero-posterior and lateral wrist radiographs to assess fracture alignment and displacement 1.
Follow-up radiographs at 7 and 15 days post-reduction, and at cast removal to monitor healing and alignment 1.
Functional assessment using tools like Quick DASH questionnaire 1.Management
First-line Treatment: Closed reduction and cast immobilization (CRCI) performed in the emergency department 1.
Sedation Methods: Procedural sedation often utilized; common agents include nitrous oxide (eN2O), ketamine, and nitrous oxide combined with intranasal fentanyl 2.
Acceptable Angulation Tolerance: Tolerance for angulation varies; generally, up to 20° or 10° in younger children without reduction, with more displaced fractures referred for surgical intervention 2.Special Populations
Pediatrics: Frequent use of nitrous oxide and ketamine for procedural sedation in pediatric emergency settings 2.
Tolerance Levels: Higher tolerance for angulation in younger children (e.g., up to 25° in ED reduction) 2.Key Recommendations
Immediate closed reduction and cast immobilization can be effectively performed in the emergency department without fluoroscopic guidance for overriding distal forearm fractures in children 1 (Evidence: Moderate).
Nitrous oxide is a commonly used and effective agent for conscious sedation during reduction procedures in pediatric patients 2 (Evidence: Expert opinion).
Angulated fractures up to 20° or 10° in younger children may be managed non-operatively, with more severe displacements requiring surgical referral 2 (Evidence: Expert opinion).References
1 Rava A, Alberghina F, Cravino M, Canavese F, Andreacchio A. Closed reduction and cast immobilization of overriding distal forearm fractures under nitrous oxide as conscious sedation without the use of imaging control. Musculoskeletal surgery 2023. link
2 Schofield S, Schutz J, Babl FE. Procedural sedation and analgesia for reduction of distal forearm fractures in the paediatric emergency department: a clinical survey. Emergency medicine Australasia : EMA 2013. link