Both-bone forearm fractures may make you feel a little nervous. A completely crooked forearm is definitely a disturbing sight. Both-bone forearm fractures (especially of the midshaft) typically require surgical intervention, but relocation of bony injuries, regardless of site or complexity, is an important and necessary skill you need to know. Plus, you will be required to assist with sedation, reduction, and splinting when the orthopedic team is involved.
Correcting and stabilizing two bones (instead of one) may seem tricky, but we are going to help you do it right. This complex procedure should be done with orthopedic consultation whenever possible. If that isn't available and the patient requires transfer or faces a long wait, this is a good way to reduce and stabilize the injury.
Why do we care about doing closed reductions for fractures if the really bad ones go to surgery anyway? And data suggest that minor pediatric bony injuries may not need reduction at all. (J Bone Joint Surg Am 2012;94:246.) It's important to know why angulation, displacement, and degree of fracture may require quick reduction. Reduction allows patients to start healing faster, restores blood flow, and relieves pain. Avascular necrosis also can set in as early as six to eight hours post-injury in many long bone fractures, such as femur fractures. Reduction, even if closed is the only option, is key to avoiding long-term complications.
Both-bone fractures in pediatric patients require immediate closed reduction in the ED. Moderate sedation carries risks, but ketamine for sedation has been proven safe and effective during closed reduction. Reductions can be lengthy (bedside fluoroscopy, manipulation, splinting, etc.), and a longer acting agent with low respiratory compromise such as ketamine is a good choice. One study found that etomidate induces effective and adequate sedation in the pediatric emergency department for painful orthopedic procedures, but ketamine, which has longer action times, might be preferred for reductions because orthopedic procedures could be lengthy. No difference was seen in recovery time for these patients. (Pediatr Emerg Care 2016;32:830.)
Ketamine is safe and cost-effective for treating displaced ulnar and radial fractures in pediatrics, with high parent satisfaction rates. (World J Orthop 2018;9:50; http://bit.ly/2NcPSkZ.) You should adhere to your department's sedation policy and always use weight-dose ketamine for your patient. Premedicate patients with ondansetron before sedation; it significantly reduces vomiting associated with IV ketamine procedural sedation in children. (Ann Emerg Med 2008;52:30.)
Ketamine has an onset of less than five minutes when administered IV or IM, with recovery averaging between 45 and 120 minutes. An intravenous dose of 1-1.5 mg/kg or an IM dose of 2-4 mg/kg will put the patient into a trance-like state with dissociative features. (Saudi J Anaesth 2011;5(4):395; http://bit.ly/2NcgEd7.) These are very conservative doses, and sometimes more is required. You may increase the dosage depending on your experience with the drug and the patient's weight, response, and level of sedation.
- Closed reduction of both-bone forearm fractures in a pediatric patient using manual manipulation
- Ketamine-induced moderate sedation and recovery
- Application of reverse sugar-tong splint
Consider using a sedation checklist before, during, and after administering sedatives. This list includes reminders such as checking Mallampati scores, setting up specific equipment, medication-dosing guidelines, and signed consent.
- Obtain all materials, including splinting items, medication, the airway cart, and other tools for sedation.
- Make sure your signed consent is completed.
- Complete a time out and tell the parents what you will do.
- Start your sedation. Await three to five minutes for the ketamine to work.
- Check your patient's sedation by carefully examining his eyes. He should have short, rapid beats and appear sedated.
- You may see a rise in heart rate or blood pressure around the three- to five-minute mark.
- The child may still be talking during your procedure, but it most likely will be unintelligible.
- This next part will require two people and two sets of hands. Have both providers wrap their fingers under the forearm on the volar surface and stabilize your thumbs on the dorsal side over the injury. Apply firm, deep pressure using your thumbs on the forearm. Push using equal pressure on the ulnar and radius. Massage the bones into place. You may hear a click or pop and feel the bones come together.
- Use bedside fluoroscopy to ensure proper reduction. You may also send the patient for formal x-rays post-splint application.
- Splint the patient with a reverse sugar-tong splint using a distal-to-proximal wrapping technique with the ACE wrap. Be sure to keep the hand in slight flexion during the splint application.
- Check the neurovascular status of the extremity.
- Complete the sedation and recovery while monitoring for any abnormal events.
- PO challenge all patients prior to discharge and ensure voiding occurs with witnessed ambulation to the bathroom. Document this in your chart.
- Watch for the common side effects of ketamine: psychological reactions, agitation, confusion, hallucinations, elevated blood pressure, tachycardia, tremors, laryngeal spasms, and vomiting.
- The effect of ketamine on respiratory and circulatory systems is unique. It will usually stimulate rather than depress the circulatory system.
- Ketamine can cause apnea, especially in higher doses, when combined with other sedative/analgesic agents or in critically ill patients.
- There is an associated increased risk of adverse respiratory events with ketamine use in children under 3 months. This is "attributable to differences in airway anatomy and laryngeal excitability" seen in this age group, and "ketamine use for procedural sedation is relatively contraindicated in children less than 3 months of age and should be used with additional caution in children 3-12 months of age." (Saudi J Anaesth 2011;5(4):395; http://bit.ly/2NcgEd7.)
- Multiple studies have shown that using ketamine and propofol together for sedation is not necessary and heightens the risk of adverse events.
Photo Tip: Jim says check the edges of your fiberglass splinting material prior to application. Fold the edges into the padding to prevent any jagged edges.
Pro Tip: We recently treated a child who broke both bones of his right arm and then broke both bones of his left arm three weeks later. That might raise your suspicion for child abuse, but also consider osteogenesis imperfecta. This rare genetic disease with dozens of subtypes and classifications may be seen in children. Look for a blue-colored sclera, short stature, loose joints, hearing loss, and severe dental disease.