Rosen & Barkin's 5-Minute Emergency Medicine Consult (277 page)

• Torus
  and
  Greenstick
  fractures with <10° of angulation may be treated with long-arm splint, sling, and orthopedic referral.
  
• Plastic deformities
  require orthopedic consultation:
  
  • Some minimally displaced plastic deformities may be placed in long-arm splint and sling.
    
• Salter–Harris
  type fractures require orthopedic consultation.
  

• Acetaminophen: 325–1,000 mg PO q4h (peds: 10–15 mg/kg q4h PO)
  
• Antibiotics:
  
  • Open fractures require IM/IV antibiotics.
    
  • Cefazolin: 1–2 g IM/IV or equivalent 1st-generation cephalosporin; if contaminated, add an aminoglycoside
    
• Codeine: 15–60 mg PO/IM q4h (peds: >2 yr, 0.5–1 mg/kg q4h PO/IM)
  
• Hydrocodone: 5–10 mg PO q4h
  
• Ibuprofen: 200–800 mg q4–8h (peds: >6 mo, 5–10 mg/kg per dose q6h)
  
• Morphine sulfate: 2–10 mg IV/IM; titrate to pain (peds: 0.1 mg/kg per dose IV/IM)
  
• Tetanus: 0.5 mL IM every 10 yr
  

FOLLOW-UP

• Open fractures
  
• Fractures with compartment syndrome or neurovascular compromise
  
• Fractures needing immediate operative management or general anesthesia for reduction
  
• Suspected nonaccidental trauma
  

• Appropriate reduction and immobilization
  
• Arranged orthopedic follow-up
  
• Adequate pain control measures
  
• Cast/splint care discharge instructions provided and understood by patient
  
• Documentation of intact neurovascular function after ED treatment
  

All fractures (or suspected fractures) discharged from ED should be referred to orthopedic surgeon for close follow-up.

All patients should be referred to an orthopedic surgeon or hand surgeon.

• Missed 2nd fracture
  
• Missed concurrent dislocation or subluxation
  
• Impending compartment syndrome
  

• Black WS, Becker JA. Common forearm fractures in adults.
  Am Fam Physician
  . 2009;80(10):1096–1102.
  
• Handoll HH, Pearce P. Interventions for isolated diaphyseal fractures of the ulna in adults.
  Cochrane Database Syst Rev
  . 2009;(3):CD000523.
  
• Madhuri V, Dutt V, Gahukamble AD, et al. Conservative interventions for treating diaphyseal fractures of the forearm bones in children.
  Cochrane Database Syst Rev.
  2013;4:CD008775.
  
• Perron AD, Brady WJ. Evaluation and management of the high-risk orthopedic emergency.
  Emerg Med Clin North Am
  . 2003;21(1):159–204.
  

CODES

• 813.23 Closed fracture of shaft of radius with ulna
  
• 813.44 Closed fracture of lower end of radius with ulna
  
• 813.80 Closed fracture of unspecified part of forearm
  

BASICS

• Foreign bodies (FBs) lodged in the external auditory canal
  
• The external auditory canal:
  
  • Cartilaginous and bony passage lined with periosteum and skin
    
  • The periosteum is extremely sensitive, making removal a painful procedure:
    
    • In small children general anesthesia may be required to remove the object
      
    • FBs usually impact at the junction of the inner end of the cartilaginous portion of the canal or at the isthmus
      
    • Innervated by the facial, glossopharyngeal, vagus nerves
      
• Inanimate foreign objects are often associated with delayed presentations:
  
  • Children often delay reporting because of fear of punishment
    
  • Often the FB is an incidental finding in children during an ear exam
    
• Physical findings may change due to length of time the object is in the canal
  
• Children with cerumen impaction or those with pica are predisposed
  
• The location is often the right ear, due to the predominance of right handedness
  
• Children and psychiatric patients may insert anything sufficiently small to enter the external auditory canal.
  
• Ear FBs are most common in children <8 yr
  
• Complications:
  
  • Canal laceration:
    
    • Usually caused by repeated attempts to remove a nongraspable object
      
  • Perforation of tympanic membrane:
    
    • More likely to result from removal procedure than the FB
      
  • Otitis externa
    
  • Malocclusion from erosion into the temporomandibular joint
    
  • Parapharyngeal abscess
    
  • Mastoiditis
    
  • Meningitis
    
  • Brain abscess
    
  • Insects may injure the tympanic membrane or canal by stinging, biting, or scratching
    
  • Button batteries can cause significant destruction due to the strong electrical currents and pressure necrosis
    
  • Typically, the most damage is caused by negative side of the battery
    
  • Damage to the facial nerve and ossicles have been reported
    
• Symptoms usually resolve within a few days after FB removal
  

• Children:
  
  • Stones
    
  • Small beads
    
  • Paper
    
  • Toys
    
  • Seeds and popcorn kernels
    
  • Beans and other food and organic materials
    
  • Button batteries:
    
    • Higher risk for necrosis than other FBs
      
• Competent adults:
  
  • Cotton-swab tips
    
  • Earplugs
    
  • Insects:
    
    • Cockroach most common in US
      
  • Hidden illicit drugs
    

DIAGNOSIS

• Decreased hearing
  
• Excessive crying in infants
  
• Unilateral ear pain
  
• Fullness
  
• Loud noises
  
• Buzzing sound (with live insects)
  
• Nausea
  
• Dizziness
  
• Ipsilateral tearing
  
• Purulent discharge from the external ear
  
• Itching
  
• Bleeding
  

• Travel or camping history or poor living conditions suggests insects in the external ear canal
  
• Inquire about previous attempts to remove the FB and any trauma associated with these attempts
  

Otoscopic exam should be performed before and after removal of the FB:

• Identify type of FB to determine removal procedure:
  
  • Button battery
    
  • Live insect
    
  • Vegetable
    
  • Inanimate object
    
  • Size
    
  • Risk of swelling when exposed to water
    
• Perform a bilateral exam; especially important in children and psychiatric patients, and prevent overlooking a quiescent FB in the contralateral ear
  
• Attempt to visualize tympanic membrane to assess for rupture
  
• Assess for otitis externa
  
• Assess for retained fragments after the removal
  
• Always exam the nonaffected ear and nostrils for additional FBs
  
• Significant pain, vertigo, or ataxia, nsytagmus, hearing loss, otorrhea, or facial nerve paralysis are concerning signs and an otolaryngologist consultation should be considered
  

Careful otoscopic exam:

• Minimize pain
  
• Gain the patient’s trust
  
• Identify the FB before attempting removal
  

None indicated

CT scan if infectious or erosive sequelae are suspected

Otomicroscope:

• May be used when standard ED techniques fail or the equipment is available to emergency medical staff
  

• Cerumen impaction
  
• Granuloma
  
• Hematoma
  
• Injury
  
• Otitis externa
  
• Perforated tympanic membrane
  
• Residual otitis externa after self-extraction of the FB
  
• Tumor
  

TREATMENT