› Pregnancy considerations
› Imaging approach
› AP and lateral forearm radiographs with abdominal shielding
› Radiation dose to fetus from extremity radiographs is minimal
› CT of the forearm with shielding when plain films equivocal
› MRI without gadolinium preferred when soft tissue assessment needed
› Analgesia in pregnancy
› Acetaminophen 500–1000 mg PO — first-line for all trimesters
› NSAIDs — avoid after 20 weeks gestation (premature ductus arteriosus closure risk)
› Short-course opioids (morphine) acceptable for severe acute pain with monitoring
› Regional nerve block preferred over systemic opioids when feasible
› Operative considerations
› Surgery generally deferred to postpartum if stable closed fracture
› If urgent surgery required, obstetric consultation for fetal monitoring
› Regional anesthesia preferred over general anesthesia when possible
› DVT prophylaxis
› Upper extremity fractures have lower DVT risk than lower extremity
› Mobilization and hydration emphasized
› Older adult considerations
› Mechanism and bone quality
› Low-energy falls sufficient due to osteoporosis
› Cortical thinning increases complexity of plate fixation
› Bone quality assessment relevant to implant selection
› Compartment syndrome risk
› Reduced compartment compliance with age-related tissue changes
› Anticoagulant use common — increases hematoma risk
› Medication considerations
› NSAIDs — use with caution
› Renal impairment risk (CrCl monitoring)
› GI bleeding risk — proton pump inhibitor co-prescription
› Opioids
› Start low, go slow principle
› Constipation prophylaxis
› Fall risk counseling during opioid use
› Operative risk assessment
› Frailty scoring for surgical risk stratification
› Cardiac and pulmonary comorbidity optimization pre-op
› Bone health assessment post-fracture
› DEXA scan if not recently performed
› Vitamin D and calcium supplementation
› Bisphosphonate consideration after fracture healing
› Pediatric Galeazzi and Galeazzi-equivalent fractures
› Pediatric anatomy difference
› Distal ulna physis is the weak point in children
› True DRUJ ligamentous dislocation rare — physeal separation predominates
› Galeazzi-equivalent: distal radial fracture with ulnar physeal separation
› Treatment approach
› Closed reduction and long-arm casting usually successful
› Reduction under procedural sedation in ED
› Long-arm cast with forearm in supination
› Orthopedic follow-up within 1 week to confirm maintained reduction
› Operative fixation indications in children
› Failed closed reduction
› Irreducible physeal injury
› Older adolescents with near-adult bone (physeal closure)
› Unstable fracture pattern with high re-displacement risk
› Analgesia in children
› Ibuprofen 10 mg/kg PO every 6–8 hours (maximum 40 mg/kg/day)
› Acetaminophen 15 mg/kg PO every 4–6 hours (maximum 75 mg/kg/day)
› Intranasal fentanyl 1.5 mcg/kg for severe pain prior to IV access
› Procedural sedation with ketamine 1–2 mg/kg IV or 4–6 mg/kg IM
› Child protection
› Mechanism inconsistent with developmental stage warrants safeguarding assessment
› Toddler fractures with unclear mechanism require skeletal survey consideration
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