What the Anesthesiologist Should Know before the Operative Procedure

Most forearm fractures in adults result from a high impact direct blow to the forearm or from falls. Motor vehicle accidents and sports trauma are commonly responsible. When referring to forearm fractures, isolated wrist or elbow fractures are excluded. Because of the complex anatomy, fracture patterns emerge, including:

Galeazzi fracture: fracture of the radius with dislocation or sprain of the distal radioulnar join.
Monteggia fracture: fracture of the ulna with dislocation, sprain, or fracture of the radiocapitellar joint.
“Nightstick” fracture: single closed fracture of the ulna resulting from a direct blow.

Apart from the “nightstick” fracture, forearm fractures require open reduction and internal fixation (ORIF) for best results. In the elderly, lower-impact falls may result in fracture due to osteoporotic bone. Traditionally, these fractures have been treated nonoperatively, but recently, more aggressive treatment including ORIF is becoming common. The goal of surgery is to maintain proper alignment and length of the bones for maximal range of motion and upper extremity function. Inadequate treatment can lead to debilitating loss of function.

1. What is the urgency of the surgery?

What is the risk of delay in order to obtain additional preoperative information?

In general, forearm fractures need to be addressed within 24 hours whether open, closed, single. or two-bone fractures. More urgency exists for open fractures due to the increasing risk of infection over time. Any forearm fracture associated with vascular injury requires emergent exploration. “Six hours from fracture to operating room” is often referred to by surgeons and anesthesiologists alike as the goal for open forearm fracture patients. Urgency is always appropriate in the setting of vascular, neural, or complex soft tissue damage. Most uncomplicated closed forearm fractures can appropriately be addressed within 24 hours of the injury.

Emergent: Open fractures of both bones of the forearm should be treated with ORIF on an emergent basis, typically less than 24 hours. In cases of open fracture with gross contamination, antibiotic therapy and surgical treatment including debridement should be initiated as soon as possible. Forearm fractures associated with vascular or neurologic injuries should be addressed emergently.

Urgent: Closed fractures of both bones of the forearm should be treated with ORIF on an urgent basis, usually within 24 hours of the injury.

Delayed repair: In circumstances of severe local soft tissue trauma with tissue loss, severe swelling or severe contamination, it may be advantageous to allow for local soft tissue recovery prior to attempted surgical repair. In cases of polytrauma or multiple severe comorbidities, it is important to address immediately destabilizing injuries/comorbidities first. In these cases, an external fixation device or traction device may be used to preserve skeletal length and alignment until ORIF is possible.

Nonoperative repair: The most clear indication for nonoperative repair (extremity immobilization with long arm cast), is the “nightstick” fracture: a closed isolated ulnar shaft fracture.

2. Preoperative evaluation

Specific preoperative evaluation for this injury should include investigation into the etiology of the fracture:

If the forearm fracture is one of many traumatic injuries, life-threatening injuries such as intrathoracic, intraabdominal, or intracranial injuries should be addressed prior to the forearm fracture.
If the forearm fracture is an isolated injury, then the preoperative evaluation can focus on the patient’s general health assessment, risk factors for anesthesia, etc.
In evaluating a patient with a forearm fracture, care should be taken to evaluate for any neurologic deficits in the injured forearm, especially if regional anesthesia is planned.
Due to the nature of the event, most patients should be considered to have a “full stomach.”
Consider drug or alcohol use if mechanism of injury is suspicious (single-vehicle motor vehicle accident, etc).

Surgery may be delayed for further patient evaluation or treatment in specific cases:

Medically unstable conditions warranting further evaluation include: any physiologic instability related to a patient’s other traumatic injuries or preexisting comorbidities.
Delaying surgery may be indicated if the patient is hemodynamically unstable due to other associated injuries, the patient requires additional work-up or treatment of serious medical conditions.
In cases of severe local soft tissue trauma and swelling, the surgeon may opt to delay the surgery for soft tissue optimization.

3. What are the implications of co-existing disease on perioperative care?

Perioperative evaluation: As stated above the history and physical exam should include a thorough evaluation of the patient’s past medical history, the etiology of the fracture, and a neurologic exam focusing on the injured forearm.

Perioperative risk reduction strategies: Because the surgical management of forearm fractures is most often considered urgent if not emergent, perioperative risk reduction strategies are somewhat limited. However, the current literature suggests that ORIF within 24 hours is acceptable. Thus, further evaluations that can help reduce perioperative risk and can be accomplished within this time frame should be sought. For example, delaying surgery for an echocardiogram in a patient with a murmur and a closed forearm fracture resulting from loss of consciousness leading to a fall is warranted. Carefully choosing an anesthetic plan suited to the patient’s comorbidities is important. Forearm fracture ORIF under a brachial plexus block and minimal sedation allows the patient to avoid the risks inherent in general anesthesia and airway manipulation, and may be considered a risk reduction strategy in certain cases.

Management of chronic medications/conditions: In the setting of chronic medications, only anticoagulation medications need to be stopped due to the trauma and if regional anesthesia is planned. If the anticoagulation is related to cardiac issues such as atrial fibrillation or intracoronary stents, consultation with the cardiologist is appropriate to develop unified perioperative management strategies. In patients who are chronically anticoagulated, follow the American Society of Regional Anesthesia (ASRA) guidelines for regional anesthesia in the anticoagulated patient.

b. Cardiovascular system

Acute/unstable conditions: Life-threatening conditions take precedence over forearm fracture repair. Splints can be made to maintain proper alignment in the affected limb.

Baseline coronary artery disease or cardiac dysfunction: goals of management: Evaluate and treat as allowed based on the urgency of the surgery as dictated by AHA/ACC Guidelines. Adapt anesthetic plan to patient’s comorbidities.

c. Pulmonary

COPD/ lung disease

Regional anesthesia: associated pulmonary risks

Supraclavicular and Infraclavicular approaches to brachial plexus block both carry a risk of pneumothorax.
Supraclavicular approach to the brachial plexus may lead to phrenic nerve paralysis on the ipsilateral side. Consider alternate approach, i.e. infraclavicular or axillary, in patients with severe lung disease or contralateral phrenic nerve paralysis, pneumonectomy, etc.
OSA Patients who are diagnosed or are at risk of obstructive sleep apnea (OSA) need to be thoroughly evaluated in terms of airway risk, surgical positioning and anesthetic choice. A regional anesthetic technique with sedation in this population requires that the anesthesiologist have easy access to the airway in case of an airway emergency with obstruction and/or apnea. When using regional anesthesia for surgical anesthesia, using the minimal sedation required for patient comfort confers some safety. However, if the patient has severe OSA and severe anxiety, the anesthesiologist must weigh the risks and benefits of a secure airway (general anesthesia) vs. deep sedation in the setting of OSA. If the OSA patient typically uses a CPAP machine during sleep at home, in many institutions it is possible to use a CPAP machine in the operating room
Reactive airway disease (asthma): Continue pulmonary medications.

d. Renal-GI:

In patients with an increased risk of aspiration (full stomach or history of severe GERD), an anesthetic regimen must be selected that protects the patient’s lungs from aspiration. This population can still benefit from regional anesthesia for postoperative analgesia, but intraoperative anesthesia choices are limited to general anesthesia with an endotracheal tube and a rapid sequence induction or regional anesthesia with minimal sedation.

e. Neurologic:

Acute issues: When considering regional anesthesia, specifically PNB, it is imperative to evaluate the post-traumatic neurologic status of the patient’s injured limb. Neurologic injury may not be an absolute contraindication to PNB, but the surgeon’s plan for postoperative neurologic assessments must be taken into account.

Compartment syndrome: Pain is usually one of the first signs of a developing compartment syndrome. In patients with dense PNB or in patients who are intubated and sedated, consistent limb and pulse checks are required in the injured limb. Direct pressure monitoring of the compartment is also an option if in doubt.

Chronic disease: There are no definitive data with regards to preexisting neurologic disease (multiple sclerosis, for example) and the safety of PNB. It is important to weigh the patient’s risk factors vs. the benefits of the PNB and address these with the patient and the surgeon to make an informed decision. For example, a morbidly obese patient with OSA and diabetic neuropathy may do best with an opioid-sparing technique (regional anesthesia) even though they may be at an increased risk of neuropathy.

f. Endocrine:

Patients with poorly controlled diabetes or thyroid dysfunction may be at higher risk of nerve injury with PNB.

4. What are the patient's medications and how should they be managed in the perioperative period?

No specific recommendations for forearm fracture other than to avoid anticoagulants in the setting of trauma.

h. Are there medications commonly seen in patients undergoing this procedure and for which should there be greater concern?

Because a forearm fracture is a traumatic event and may occur in all types of patients, there are no specific medications or conditions commonly seen in patients undergoing this procedure.

i. What should be recommended with regard to continuation of medications taken chronically?

Cardiac: Continue beta blockers, antihypertensives

Pulmonary: Continue pulmonary meds

Renal: Continue

Neurologic: Continue

Antiplatelet: Hold antiplatelet agents, plan bridging strategy for cardiac anticoagulants as discussed above

Psychiatric: Continue

j. How To modify care for patients with known allergies –

Avoid known allergens. If exposure is certain and necessary, consider pretreatment of the patient with H1 and H2 blockers and steroids.

k. Latex allergy- If the patient has a sensitivity to latex (eg. rash from gloves, underwear, etc.) versus anaphylactic reaction, prepare the operating room with latex-free products.

N/A

l. Does the patient have any antibiotic allergies-

Preoperative antibiotics are universally indicated for open and/or contaminated wounds. In the case of a patient allergy, alternative antibiotics are given per SCIP recommendations. October 2010 SCIP recommendations: cefazolin is the first line agent of choice; in the setting of a beta-lactam allergy, vancomycin or clindamycin is appropriate.

m. Does the patient have a history of allergy to anesthesia?

Malignant hyperthermia (MH)

Documented

Proposed general anesthetic plan: avoid all trigger agents such as succinylcholine and inhalational agents.
Ensure MH cart available [MH protocol]
Family history or risk factors for MH: similar precautions as documented MH.
Consider regional anesthesia as an alternative to general anesthesia when the risk of compartment syndrome is small.

Local anesthetics/ muscle relaxants: documented

Local anesthetic allergy: If the allergy is to the amino-ester local anesthetics, amino-amide compounds may be used without concern for cross-reactivity. Otherwise, avoid peripheral nerve blockade; avoid local anesthetics.
Muscle relaxants: Consider advantage of PNB as a substitute for muscle relaxants to “relax the muscles”.

5. What laboratory tests should be obtained and has everything been reviewed?

The choice of laboratory tests should be guided primarily by the patient’s medical conditions and risk factors. Coagulation studies are indicated in trauma patients and in patients in whom regional anesthesia is planned who are at risk for a coagulopathy.

Common laboratory normal values will be same for all procedures, with a difference by age and gender.

Hemoglobin levels: Obtain in all trauma patients.

Electrolytes: Obtain in all trauma patients, patients with renal failure, patients on diuretics.

Coagulation panel: Obtain in all trauma patients.

Imaging: As dictated by patient’s history.

Other tests: As dictated by patient history.

Intraoperative Management: What are the options for anesthetic management and how to determine the best technique?

ORIF of forearm fractures can be accomplished under various forms of anesthesia: general anesthesia alone, PNB alone or with sedation, general anesthesia for intraoperative anesthesia with a PNB placed for postoperative pain control. The best technique should balance patient’s comorbidities with the risks and advantages of the anesthetic technique chosen. For example, a straight regional technique might be the best choice for a relatively healthy patient with an isolated forearm fracture, but may be a poor choice for patients who have multiple injuries or are unable to cooperate.
The surgical approach for forearm surgery can be accomplished in most cases with the patient supine with the operative arm abducted. In certain fractures of the ulna, the surgical approach may be better with the patient prone.
Both muscle relaxation and/or a dense motor block facilitate reduction of the fracture.
The operating room table will often be turned 45-90 degrees to give the surgeon proper access to the arm.
Fasciotomy: The surgeon may choose to perform a prophylactic fasciotomy at the time of surgical repair to minimize the risk of postoperative compartment syndrome.

Regional anesthesia

Based on the anatomic location of forearm fracture repair, neuraxial anesthesia is not a good choice. Instead, a PNB of the brachial plexus via the supraclavicular or infraclavicular approach is reasonable.
It is critical to be aware of risk of compartment syndrome with forearm fracture and the decision to place a PNB will depend on each specific situation.
Goals of regional anesthesia for these cases should include: providing good pain management, avoiding masking a compartment syndrome and preventing a delay in surgical decompression.
Airway: forearm fracture repair can be accomplished under regional anesthesia (supraclavicular, infraclavicular or axillary brachial plexus block) with or without sedation or general anesthesia. Consider patient’s airway anatomy, body habitus, surgical positioning when deciding whether to secure the airway.

Single injection or continuous PNB

Benefits

Avoidance of general anesthesia and manipulation of the airway. Good pain control lasting beyond the early postoperative period.
The dense motor block associated with a “surgical block” relaxes the musculature and facilitates reduction of the fracture.
Can be used primarily to provide postoperative pain control when used with a general anesthesia for surgery.

Drawbacks: risks of PNB

Nerve damage
Infection
Pneumothorax: associated with supraclavicular and infraclavicular approaches to the brachial plexus block.
Phrenic nerve block: associated with supraclavicular approach.

Issues

Coagulation status: Follow the American Society of Regional Anesthesia (ASRA) guidelines for regional anesthesia in the anticoagulated patient.
Neurologic status: Thoroughly evaluate the patient’s injured limb’s neurologic status pre-block placement.
Compartment syndrome: regional anesthesia may mask symptoms of compartment syndrome. Therefore, a PNB should not be placed or dosed until after the risk of compartment syndrome has resolved.
Approaches: Supraclavicular, infraclavicular, or axillary approaches to the brachial plexus can be used for surgical anesthesia and /or postoperative analgesia. If a continuous block is desired, a catheter can be placed in either the supra- or infraclavicular approaches. The choice should be based on desired duration of block, analgesic goals, and patient anatomy.

b. General Anesthesia

Benefits: Complete anesthesia/amnesia during case; muscle relaxation possible which facilitates reduction of the fracture.

Drawbacks: Postoperative pain control reliant on systemic medications (opioids), airway manipulation, other risks of GA including nausea/vomiting.

Airway concerns: Forearm fracture patients may present with a cervical spine collar in place (depending on mechanism of injury), complicating the approach to the airway.

c. Monitored Anesthesia Care:

Monitored Anesthesia Care in combination with a PNB of the brachial plexus from either the supraclavicular, infraclavicular or axillary approach can provide excellent surgical anesthesia for ORIF of the forearm.

6. What is the author's preferred method of anesthesia technique and why?

Because forearm fractures result from trauma, individual circumstances, preexisting comorbidities, and associated injuries, a careful anesthetic plan will minimize risks, complications and improve recovery.

In an otherwise healthy patient with an isolated fracture and low risk for compartment syndrome, a brachial plexus PNB with sedation is a reasonable approach. In certain circumstances, patient anxiety or an inability to lie still, a general anesthesia or heavy sedation in addition to the brachial plexus block may be indicated.
In patients with a potential difficult airway, morbid obesity or a diagnosis of obstructive sleep apnea, it may be best to secure the airway prior to the beginning of surgery, since the head of the operating room table is often turned away from the anesthesiologist during the case. These patients do well with a general anesthesia for the case and a brachial plexus block placed preoperatively for postoperative pain control (thereby minimizing opioids). Laryngeal mask airway (LMA) usage in this patient population is limited by the anesthesiologist’s goals, the surgeon’s goals and the patient’s airway and body habitus: If the surgeon requests muscle relaxation for the operation, the LMA is not typically the best airway option in an obese individual, as ventilation may require higher pressures than in smaller patients.
Polytrauma: regional anesthesia may not be practical because of multiple injuries or because the patient is already intubated and sedated.
Anticoagulation: in patients with abnormal coagulation parameters, the decision to place a PNB must be balanced by the risks of bleeding around the nerve, ability to compress or tamponade bleeding (supra- and infraclavicular difficult to compress; axillary artery much more accessible) and the benefits of avoiding a general anesthesia and airway manipulation (severe COPD, etc). For example: a single shot axillary brachial plexus block for surgical anesthesia with light sedation for patient comfort may be a reasonable choice for a patient with borderline coagulation parameters whose risk of morbidity associated with general anesthesia is high.

What prophylactic antibiotics should be administered?

Cefazolin; if beta-lactam allergic, vancomycin or clindamycin (SCIP October 2010 recommendations).

What do I need to know about the surgical technique to optimize my anesthetic care?

The surgical approach for a complex ulnar fracture sometimes requires a prone position. All other surgeries are typically accomplished with the patient supine.
Forearm fracture repairs typically require an upper arm tourniquet. The tourniquet should be released prior to full closure to ensure hemostasis.

What can I do intraoperatively to assist the surgeon and optimize patient care?

Muscle relaxation or PNB to facilitate reduction.

Complications

Cardiac: None specific to forearm fracture; evaluate patient’s co-morbidities.

Pulmonary: Anticipate possible pneumothorax in trauma patients. If using supraclavicular peripheral nerve blockade, be aware that phrenic nerve may be blocked and patient may develop otherwise unexplained shortness of breath.

Neurologic:None specific to forearm fracture. Evaluate for head injury in trauma patients.

a. Neurologic:

Unique to procedure: None specific to forearm fracture. If the patient has multiple long-bone fractures in addition to forearm fracture, be aware of possibility of fat embolism, hemorrhage, and coagulopathy.

b. If the patient is intubated, are there any special criteria for extubation?

There are no special criteria for extubation specific to forearm fracture surgery, other than consideration of the mechanism of injury (e.g., a polytrauma patient may have other reasons for delayed extubation: lung contusion, etc). Airway management should be carried out specific to each individual’s needs and preexisting comorbidities (COPD, difficult airway, etc).

c. Postoperative management

What analgesic modalities can I implement?

A continuous brachial plexus PNB using ropivacaine or bupivacaine can provide excellent pain control and thus minimize opioid requirements during the postoperative period. If a brachial plexus block is contraindicated, systemic opioids will be the primary pain control mechanism. Use of a multimodal regimen (including NSAIDs if bleeding is not an issue) may help reduce nausea and dysphoria associated with opioids.

Regional anesthesia in patients at risk of compartment syndrome: place a brachial plexus block after the risk of compartment syndrome has resolved. Alternatively, place a brachial plexus catheter prior to surgery and delay dosing until after the risk of compartment syndrome has resolved.
Discharge: Certain patients with isolated forearm fractures and at low risk for compartment syndrome may be discharged home with a brachial plexus nerve block catheter in situ connected to a disposable local anesthetic infusion pump. These patients typically do very well and have minimal problems with pain management. Thorough preoperative education and postop follow-up must be ensured.

What level bed acuity is appropriate?

Bed level acuity is entirely dependent on the patient’s comorbidities or other injuries. An otherwise healthy patient with an isolated forearm fracture may be housed on the lowest acuity ward.

What are common postoperative complications, and ways to prevent and treat them?

Short term: specific to this case: be on lookout for compartment syndrome. All other potential postoperative complications are nonspecific.
Long term: poor surgical outcome, neurologic deficits.

What's the Evidence?

Browner, BD. “Skeletal trauma: basic science, management, reconstruction”. 2008. (Definition of forearm fractures and description of surgical management.)

“Prophylactic antibiotic regimen for surgery. Surgical Care Implementation Project: A National Quality Partnership”. October 2010. (Describes most recent prophylactic antibiotics regimen for surgery.)

Chung, K. “Trends in the United States in the treatment of distal radial fractures in the elderly”. J Bone Joint Surg Am. vol. 91. 2009. pp. 1863-73. (Describes surgical management of forearm fractures.)

Liporace, F. “Distal radius fractures”. J Orthop Trauma. vol. 23. 2009. (Describes definition and management of distal radius fractures.)

Boezaart, A. “Anesthesia and orthopedic surgery”. 2006. (General information on anesthesia for orthopedic surgery.)

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