How should a long-term care (LTC) resident with a diagnosed age-indeterminate impacted fracture of the radial neck be treated and does emergency department (ED) referral require?

Management of Radial Neck Fracture in SNF Resident

This patient does not require emergency department transfer and can be managed conservatively at the skilled nursing facility with orthopedic consultation arranged on an outpatient basis within 1-2 weeks.

Immediate Management at SNF

Pain Control and Immobilization

• Provide appropriate pain management immediately with oral analgesics (acetaminophen, NSAIDs if not contraindicated, or opioids for severe pain) 1
• Apply a posterior long-arm splint or sling for comfort and immobilization 1, 2
• The sling may be worn for comfort only and can be discarded as early as the patient's pain allows 1

Why ED Transfer is NOT Required

• The fracture is described as "age-indeterminate," meaning it may be chronic or subacute rather than acute 2
• Impacted radial neck fractures in adults are typically stable injuries that do not require emergent surgical intervention 3
• The patient is ambulatory enough to have complaints evaluated, suggesting no neurovascular compromise
• There is no mention of open fracture, neurovascular deficit, or compartment syndrome—the only true emergencies requiring immediate ED transfer

Outpatient Orthopedic Referral

Timing and Urgency

• Arrange orthopedic consultation within 1-2 weeks for definitive treatment planning 2, 4
• Most radial neck fractures in elderly patients can be managed non-operatively with good functional outcomes 5

Treatment Expectations

• Non-operative management is the likely treatment path for this elderly SNF resident with an impacted fracture 5, 3
• The majority of simple radial neck fractures are stable, even when displaced up to 2mm 3
• Operative intervention (open reduction and internal fixation) is reserved for: displaced fractures with >3 fragments, unstable fractures where anatomic reduction cannot be achieved, or fractures with mechanical block to motion 3

Early Rehabilitation at SNF

Range of Motion Exercises

• Begin gentle range-of-motion exercises including shoulder, elbow, wrist, and hand motion within the first few days once pain is controlled 1, 6
• Critical caveat: Avoid overly aggressive physical therapy which may increase risk of fixation failure or re-injury 1, 6
• Above chest level activities should be restricted until fracture healing is evident 1

Progressive Mobilization

• Early introduction of physical training and muscle strengthening is recommended once initial pain subsides 5
• Patient should be allowed to use the arm for light activities of daily living as tolerated 1

Multidisciplinary Assessment

Comprehensive Evaluation

• Systematic assessment should include evaluation of comorbidities, nutritional status, medications (anticoagulation status), and cognitive function 5
• Assess for adequate calcium (1000-1200 mg/day) and vitamin D (800 IU/day) intake to optimize bone healing 1, 5
• Consider osteoporosis evaluation and treatment given this is a fragility fracture in an elderly patient 1

Fall Risk Assessment

• Identify and address modifiable fall risk factors including environmental hazards, medications causing sedation/orthostasis, and mobility limitations 1
• Implement fall prevention strategies at the SNF 1

Monitoring and Follow-up

Clinical Monitoring at SNF

• Monitor for increasing pain, swelling, or loss of function that might indicate displacement or complications 5
• Assess neurovascular status (radial pulse, sensation, finger motion) daily for the first week 3
• Regular assessment of healing progress and functional improvement is necessary 5

Red Flags Requiring Urgent Reassessment

• Development of neurovascular compromise (numbness, weakness, absent pulse, cold extremity)
• Severe uncontrolled pain despite adequate analgesia
• Signs of compartment syndrome (progressive pain out of proportion, pain with passive stretch)
• Inability to participate in basic ADLs due to mechanical block

Key Clinical Pearls

The "age-indeterminate" descriptor on radiology is crucial—this suggests the fracture may not be acute, making emergent intervention even less necessary 2. Many elderly patients with chronic impacted radial neck fractures remain asymptomatic or minimally symptomatic and do well with conservative management 3.

Avoid the common pitfall of over-treating stable radial neck fractures in elderly patients. Prolonged immobilization and unnecessary surgical intervention are associated with worse outcomes, most commonly manifesting as significant elbow stiffness 4. The goal is early mobilization with pain control, not rigid immobilization 1, 5.