Acute onset, left arm deformity


• Scene – exam; splint with cardboard in anatomical position; ice pack applied to arm

• En route – vitals monitored

• Hospital – X-ray, conscious sedation, reduction and cast


• Response to treatment – no changes en route. Pain 6/10, didn’t want “a shot.”

• Disposition – not known


Elliot Williams, Paramedic Woodburn AmbulanceMatthew Hansen, MD Associate Professor Oregon Health & Science University

David Sheridan, MD Associate Professor Oregon Health and Science University

Brett Anderson, Paramedic Woodburn Ambulance Service


David M. Spiro, MD, MPH Professor of Pediatrics University of Arkansas Medical Center

Douglas Baker, MD Professor Johns Hopkins University School of Medicine

Craig Warden, MD Oregon Health & Science University


• Forearm fracture

Differential Diagnosis

• Fracture (open vs closed)

• Contusion

• Sprain

• Dislocation

Patient Workup History:

• Patient states – He was playing soccer, tripped on the ball and fell to the ground. Another player then stepped on his arm, breaking it. Denies nausea, LOC, any other trauma. Patient also refuses IV and pain medication en route.

Physical Exam:

• GCS: 15

• Physical findings – Deformity to left forearm, mid-shaft fracture of radius, ulna; closed fracture.

• No changes to sensory, motor, pulse.

• Physical exam otherwise unremarkable and atraumatic.

• Isolated injury

Key Points

• Treatment of pain is key to management of fractures.

• Anti-nausea agents such as Zofran (Ondansetron) are helpful as extreme pain can induce nausea.

• Evaluation for open fracture is important, as well as careful documentation of the neurologic examination.

Editor’s Notes

Look at the picture of the deformity. Impressive! Key is stabilization, inspection of the injury for an open fracture and careful documentation of the exam. Treat the pain associated with this injury, although immobilization itself reduces pain and discomfort.

-David Spiro, MD

Suggested Approach Notes

• Prehospital care of extremity fractures focuses on providing stabilization, analgesia, and performance of a basic exam to determine if there is any neurovascular compromise. The most critical part of the neurovascular exam is the pulse, temperature, and capillary refill of the affected extremity distal to the fracture. Immobilization with a basic splint can provide significant pain relief to patients with fractures and opioids can provide effective analgesia in patients with moderate or severe pain. In addition, in patients with obvious extremity fractures, other injuries should be considered and the history and exam should evaluate for spinal tenderness and signs of other significant injuries. Suggested referencesForearm fractures


• Gender: Male

• Age: 9 years

• Height: Not Available

• Weight: Not Available


• Temperature: Not Available

• Blood Pressure: 94/53

• Heart Rate: 70

• Respiratory Rate: 20

• Pulse Oximetry: 97% RA

Signs and Symptoms

Left arm deformity; pain

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