This case conference discusses a 31-year-old male patient who was in a motorcycle accident 3 hours prior. He has abrasions on his face and left leg, and swelling and tenderness in his left forearm. An x-ray reveals a closed fracture of both bones in the left forearm. The patient is given morphine and his arm is placed in a long arm splint before being admitted for observation to monitor for compartment syndrome. The discussion then reviews anatomy of the forearm bones, mechanisms of injury, management, treatment including closed or open reduction depending on the patient, and complications of forearm fractures like malunion or compartment syndrome.

1. Case conference
Ext.Wanchai Wilaisakulnam

2. Patient profile
• ผู้ป่วยชาย 31 ปี
• ประสบอุบัติเหตุขี่รถจักรยานยนต์ชนรถกระบะ 3 ชั่วโมงก่อนมา รพ. ไม่สลบ จา
เหตุการณ์ได้ มีแผลฉีกขาดที่หน้า ปวดบวมผิดรูปแขนซ้าย

3. Primary survey
• A : can talk, can move neck
• B : CCT negative, equal BS
• C : vital sign stable
• D : E4V5M6, pupils 3 mm RTLBE

4. Primary survey
• E:
• Lt.Forearm: Swelling, Tender, Bony stepping at dorsal
can pronate and supinate, Sensory intact, Can Flex and
Extend wrist, Capillary refill <2 Sec
• Abrasion wound at leg Φ 1x1 cm

5. Secondary survey
• A : ไม่แพ้ยา แพ้อาหาร
• M : no medication
• P : no U/D
• L : 3 hr
• E : ขี่จักรยานยนต์ชนรถกระบะ

6. Physical examination
• Left forearm :
• Swelling, Tender, Bony stepping at dorsal can’t pronate
and supinate, Sensory intact, Can flex and extend
wrist,Capillary refill <2 Sec
• Neurovascular intact

7. Investigation

9. Diagnosis
“Closed fracture both bone left forearm”

10. Initial management
• Morphine 40 mg IV stat
• Close reduction and apply long arm AP slab left arm
• Admit
• Observe compartment syndrome

12. Fracture both bone
forearm

13. Anatomy

14. Mechanism of injury
• Fall on out stretched arm

15. Fractures of the Forearm Bones
• Commonly radio-ulnar fracture, but sometimes
only involving either.
• Severe displacements can occur in adults, but
rarely in children except high velocity mechanism
• Displacements include:
• Angulation: medially or anteriorly
• Shift in any direction
• Rotation

16. Management
• ABC
• Limb neurovascular function.
• Examine the wrist, elbow and forearm for
tenderness and range of motion.
• Other injuries.
• Immobilise the forearm and upper arm while
waiting for X-ray.
• Provide analgesia.

17. Treatment
Children(Green stick fracture):
• Conservative: Closed reduction by manipulation
under GA, and immobilization in above elbow cast.
• Assess after a week and 8th week. Advise hand and
shoulder exercise; avoid contact sport.

18. Treatment
Adult or child in high velocity mechanism:
• Close reduction is difficult, and may re-displaced
even in the cast.
• Open Reduction and Internal Fixation (ORIF)
• Compression plate is preferred
• Bone grafting in fracture > 3 weeks
• Advise to move the limb; to prevent rigidity

20. Operative
Indication
• Open fracture
• Unacceptable alignment after reduction more than
twice
• Compartment syndrome
• Neurovascular compromise
• Refracture

21. Follow up
• weekly radiographs for first 3-4 weeks to monitor
reduction
• casting for 6-12 weeks total

22. Complication
• Malunion
• Premature or partial physeal arrest
• Cross-union Nonunion
• Compartment syndrome
• Infection
• Neurovascular injury

23. Compartment Syndrome
DEFINITION
• Elevated tissue pressure within a closed fascial
space
• Reduces tissue perfusion - ischemia
• Results in cell death - necrosis
• True Orthopaedic Emergency

24. Compartment Syndrome
Etiology
Compartment Size
• tight dressing; Bandage/Cast
• localised external pressure; lying on limb
• Closure of fascial defects
Compartment Content
• Bleeding; Fractures, vascular inj, bleeding disorders
• Capillary Permeability;
• Ischemia / Trauma / Burns / Exercise / Snake Bite / Drug Injection
/ IVF

25. Diagnosis
• The 6 P’s:
• Pulselessness
• Pallor
• Paralysis
• Pain with passive stretch
• Paresthesia/hypoesthesia
• Palpably tense compartment

26. Compartment Syndrome
Emergent Treatment
• Remove cast or dressing
• Place at level of heart
(DO NOT ELEVATE as elevation reduces the arterial
inflow and the arterio-venous pressure gradient
Alert OR and Anesthesia
• Medical treatment- Supplemental oxygen
administration
• Ensure patient is normotensive

27. Surgical Treatment
•Fasciotomy
•All compartments !!!

28. Thank you