What is the treatment for a displaced radial fracture midway down the shaft in the Emergency Department (ED)?

Treatment of Displaced Radial Shaft Fracture in the Emergency Department

A displaced radial fracture midway down the shaft requires closed reduction followed by rigid immobilization with a sugar-tong splint in the ED, with urgent orthopedic referral for surgical evaluation, as these fractures typically require operative fixation for optimal outcomes. 1

Immediate ED Management

Initial Assessment and Reduction

• Perform closed reduction immediately to restore anatomic alignment, as displaced midshaft radial fractures are inherently unstable 1, 2
• Assess for neurovascular compromise, particularly median nerve injury which commonly complicates radial fractures 1
• Obtain post-reduction radiographs to confirm acceptable alignment (displacement <3mm, angulation <10°) 3, 4

Immobilization Strategy

• Apply a sugar-tong splint for initial rigid immobilization following closed reduction 1
• This provides superior stability compared to removable splints, which are only appropriate for minimally displaced fractures 3
• Midshaft fractures require rigid immobilization due to their inherent instability from deforming muscle forces 1

Disposition and Surgical Planning

Indications for Surgical Referral

• Most displaced midshaft radial fractures require operative fixation because:
  • Post-reduction displacement >3mm indicates surgical management 3, 4
  • Midshaft location makes these fractures biomechanically unstable 1
  • Combined radius-ulna fractures generally require surgical correction 1
• Arrange urgent orthopedic consultation (within 24-48 hours) for surgical planning 5

Operative Considerations

• Surgical options include open reduction with internal fixation (plate-and-screw fixation) or minimally invasive intramedullary fixation 5
• Regional anesthesia with supraclavicular brachial plexus blockade provides superior early pain control compared to general anesthesia, with patients experiencing pain onset at a median of 11 hours versus 1 hour postoperatively 6

Post-Immobilization Care

Early Mobilization

• Initiate active finger motion exercises immediately to prevent stiffness, which does not adversely affect adequately stabilized fractures 3, 7
• Early wrist motion is not necessary following stable fracture fixation 3

Follow-up Protocol

• Obtain radiographic follow-up at approximately 3 weeks and at immobilization removal to confirm adequate healing 3, 7
• Monitor for immobilization-related complications (skin irritation, muscle atrophy) which occur in approximately 14.7% of cases 3, 7

Critical Pitfalls to Avoid

• Do not use removable splints for displaced midshaft fractures—these are only appropriate for minimally displaced distal radius fractures 3
• Do not delay orthopedic referral, as displaced midshaft fractures have poor outcomes with nonoperative management alone 1
• Always assess for associated ulnar fractures, as combined fractures mandate surgical intervention 1