Orris

A 22yrs old boy have undergone accident in yesterday early mrng at 5 o clock hs radius got brokenn. Few cm below the mid shaft and got displaced a bit on consultation with d orthopaedics he suggested to u proceed with a surgery using titanium rod in today evening and asked to be in fasting from afternoon and now h the patient was sleeping and moving the hand in diff is there any prblm in changing that position of hand

Reading File
Finding Sources
Finding Sources
Searching the Web

radius shaft fracture before surgery splint elevation compartment syndrome warning signs patient movement fasting

Searching PubMed

"forearm fractures" AND "compartment syndrome"

Slight movement of the hand while he sleeps is normal and usually harmless. Moving the hand or changing its position is fine as long as the arm stays supported in its splint or sling. Gently adjusting it is also fine, and it is better than leaving it stuck in one awkward position.
What to do
  • Keep the splint or sling on. Don't remove it. Don't let him use the hand to grip, lift or twist, and don't let him put weight on it.
  • Elevate the arm. Rest it on a pillow at about heart level or slightly above. Keep the hand higher than the elbow. This limits swelling, which matters in the hours before surgery.
  • Protect the elbow and wrist. Support the forearm along its whole length. Don't let it hang off the bed or twist.
  • Don't try to straighten or "set" the bone. Don't pull or massage the forearm.
  • Keep the fingers free. Encourage gentle finger movement while he is awake. Check that the bandage or splint isn't tight.
  • Don't give him food or water, as the orthopaedic team advised. Ask the ward staff about any painkillers or IV fluids.
Warning signs: tell the nurse or doctor straight away After a forearm fracture, the main danger is compartment syndrome, where swelling builds up pressure inside the forearm muscles. The textbooks flag forearm fractures as a risk for it.
  • Pain that is severe, getting worse, or out of proportion to the injury, or pain not relieved by the prescribed painkillers.
  • Pain when the fingers are gently stretched or moved passively. Rockwood and Green's Fractures in Adults, 10th ed. and Schwartz's Principles of Surgery both describe this as the most sensitive early sign.
  • A forearm that is tense, hard or increasingly swollen.
  • Numbness or tingling in the fingers, or weakness in moving them.
  • Pale, bluish or cold fingers. Weak pulses and paralysis are late signs, and a normal pulse does not rule out compartment syndrome (Schwartz, "Compartment Syndrome").
If any of these appear, the splint or bandage may need loosening and the surgeon should be called urgently. Don't wait for the evening.
Other points
  • A displaced fracture can shift a little with movement. This can cause a sudden increase in pain, a visible change in the arm's shape, or skin tenting over the bone. Report any of these.
  • It is normal to be drowsy and to twitch or move the arm in sleep, especially if he has had painkillers. There is no need to wake him to check, but have someone look at the fingers' colour, warmth and swelling every few hours.
  • Rockwood and Green notes that patients having both-bone forearm fixation are routinely admitted overnight after surgery for compartment syndrome monitoring. So staff will keep watching afterwards too.
Sources and limits
  • Sources: Rockwood and Green's Fractures in Adults 10th ed ("Compartment Syndrome" and "Postoperative Care"); Campbell's Operative Orthopaedics 15th ed (a forearm fracture should raise suspicion of compartment syndrome); Schwartz's Principles of Surgery 11th ed.
  • A recent PubMed check found nothing new that changes this advice.
  • This is general guidance. Follow the ward team's instructions about positioning, fasting and painkillers, because they can see the actual X-rays and splint.
I hope the surgery goes well and he recovers quickly.
attachment
attachment

He kept it in this position

analyse_media
I could view the photo directly, but the image tool failed, so this is from my own look at it. It is only a photo, so I can't judge swelling, finger colour or how tight the splint is.
What I can see
  • He is asleep on his side, hugging a pillow.
  • The forearm and hand are in a white plaster or bandaged splint.
  • The elbow is bent very sharply, so the splinted forearm is folded back up beside his head.
  • The splinted hand is higher than the elbow and is resting on the pillow.
  • He does not seem to be lying on the injured arm.
What is fine
  • Resting the arm on a pillow, with the hand higher than the elbow, helps swelling. This is the right idea.
  • He is not lying on the fracture.
What I would change
  1. Open the elbow up. A fully folded elbow for hours can squeeze the swollen forearm and the vessels at the elbow crease. It also strains the splint and the fracture site. Ideal is about 90 degrees, with the forearm resting along a pillow in front of him. A sling or a pillow under the forearm works.
  2. Keep the hand and fingers free. Part of the hand is tucked against the pillow and his face, and I can't see the fingertips. Make sure the bandage isn't pressing the fingers and that they aren't squeezed against anything.
  3. Don't let the weight of his head or body rest on the arm, especially after he falls deeper asleep.
  4. Go back to the compartment syndrome checks from before. His brow looks slightly furrowed. That may just be sleep, but ask him whether the pain is increasing. Look at the fingers when he is awake.
    • Check they are pink and warm, with no marked swelling.
    • Check there is no new numbness, and that he can move the fingers.
    • Check the pain doesn't spike when you gently move the fingers.
Moving him is safe if you do it gently. Support the splinted forearm with one hand under it, and don't twist or pull. If he is still deeply asleep, a nurse can do it with you.
Call the nurse or doctor straight away if
  • the pain is severe or increasing, or the fingers are pale, blue, cold or numb
  • the forearm feels tight or hard
  • the splint looks too tight or has slipped
  • the arm looks more deformed or the skin is tented over the bone
If none of these are present, repositioning is just a comfort and safety adjustment. Tell the ward staff, and they can give a proper sling or arm pillow.This photo helps. I'm going by the picture alone, so I can't check pain, swelling, finger colour or how tight the bandage is.
What I can see
  • A below-elbow, bandaged splint or plaster. It runs from the upper forearm over the wrist and palm.
  • The elbow is free, which is good.
  • The arm is lying on the bed pad, supported along its length. The wrist is straight and the hand is not hanging.
  • There is a thick cotton wad with string loops at the finger end. I'm not sure what it is. It may be padding or ties for some of the fingers or the thumb, so ask the nurse.
  • The bandage is dry and clean. There is no visible blood or seepage.
What worries me
  • The fingertips are barely visible. Only a small bit of skin shows at the tip. If the fingers are wrapped or covered, nobody can check their colour, warmth or movement.
  • The thread and cotton loops could tighten if the hand swells or the arm is moved. Check that nothing is pulling on or squeezing the fingers.
What to do now
  1. Check the fingertips. Look at the nails and tips of the fingers and thumb when he is awake.
    • They should be pink, not pale, blue or dusky.
    • Press a nail and release. The colour should return within 2 seconds.
    • They should be warm, with no marked swelling.
    • Ask him to wiggle each finger. Ask if there is numbness or tingling.
  2. Ask the nurse to expose the fingertips if they are covered, and to confirm the bandage isn't too tight.
  3. Prop the hand up on a pillow so it sits slightly above the elbow. At the moment it is flat on the bed pad, which is acceptable but less ideal.
  4. Keep the arm straight on the pillow. This is better than the fully folded position in your first photo.
Call the nurse or surgeon straight away if
  • the pain is severe, increasing, or not eased by painkillers
  • the fingers are pale, blue, cold or numb
  • he can't move the fingers
  • the bandage feels tight or the forearm swells
Do not try to cut or remove the bandage yourself. If the fingers look bad, a nurse or doctor can loosen it, and that is urgent.
If the fingertips are pink and warm, he can move them, and the pain is manageable, the position looks acceptable until surgery. Also let the surgical team know he was sleeping with his elbow fully bent and the arm tucked under his head.This position is better than the first one. I'm going by the photo only, so I can't judge pain, swelling or how tight the bandage is.
Better
  • The elbow is now bent roughly 90 degrees, not fully folded.
  • The forearm lies flat and supported on the bed pad.
  • The wrist is straight and the hand isn't hanging.
  • The bandage is clean and dry, with no blood or seepage.
  • The elbow is free of the bandage.
Still worth checking
  1. Fingertips. A few fingertips are just visible at the top, but I can't tell their colour from the photo. Press a nail and release. The pink colour should come back within 2 seconds. The tips should also be warm, not swollen, and the fingers should wiggle without causing more pain. Also ask whether he has numbness or tingling.
  2. The black band near the fingertips. Something dark looks like a ring or rubber band near the fingers at the top. I'm not certain what it is. If it is a rubber band or hair tie around a finger, ask the nurse to remove it now. It can cut off circulation as the hand swells.
  3. The cotton wad and string loops on the thumb side. The staff probably put these there deliberately. Make sure the strings aren't tight around the thumb or fingers, and ask the nurse what they are for.
  4. Elevation. The hand is level with the bed. A pillow under the forearm, so the hand sits a little above the elbow, would help reduce swelling.
  5. The elbow skin. There is a pale scuffed patch on the point of the elbow, probably a graze or dry skin. Mention it to the nurse, as it matters for skin cleaning before surgery.
For the nurse or surgeon, straight away
  • Severe or worsening pain, or pain on gently moving the fingers.
  • Pale, blue, cold or numb fingers, or fingers he can't move.
  • A tight, hard forearm, or a bandage that feels too tight.
His other hand is resting on his chest, and its nail beds look pink. That is just a comparison, since it is the uninjured side. Compare the injured hand's fingertips against it.
If the fingertips are pink and warm, he can move them, and the pain is controlled, he can rest like this until surgery. Please check on him every couple of hours until then.

He need to be in fasting till the surgery he can take any liquid forms

Finding Sources
Searching the Web

ASA preoperative fasting guidelines clear liquids 2 hours solids 6 hours 8 hours fatty meal adults

Please don't give him anything by mouth unless the anaesthetist or surgical team says so. The instruction he was given (fasting from the afternoon) comes from the team who will operate, and it overrides the general rules below.
What the guidelines say
  • For healthy adults having elective surgery, the American Society of Anesthesiologists says clear liquids are allowed up to 2 hours before anaesthesia. Solids and non-clear fluids need a longer gap:
    • Light meal: at least 6 hours.
    • Fried or fatty food or meat: 8 hours or more.
  • Miller's Anesthesia and Sabiston's Textbook of Surgery say the same, and describe the old "nothing after midnight" rule as outdated for most patients.
  • Clear liquids are water, black tea or coffee without milk, and juice without pulp. Milk, tea or coffee with milk, pulpy juice, and soups with solids don't count as clear. They are treated like food.
Why his case may be stricter
  • Miller's applies these timings to patients without increased aspiration risk. Pain, trauma and opioid painkillers slow gastric emptying, so many hospitals keep injured patients strictly nil by mouth. His case may fall under this.
  • Evening surgery times often shift. If the team brings it forward, a recent drink could delay or cancel the operation.
  • Aspiration of stomach contents during anaesthesia is the risk that fasting prevents.
What to do
  1. Ask the ward nurse or anaesthetist, "Can he have sips of water, and until what time?" Get a specific time.
  2. If he is allowed fluids, offer only plain water or other clear fluids, in small amounts, and stop at the cut-off time.
  3. If he is very thirsty, ask for a wet swab or sips to rinse his mouth. Rinsing and spitting out is usually acceptable, but check first.
  4. If the fast is long, ask whether he needs IV fluids. They are common, and they prevent dehydration.
  5. Tell the team about anything he has eaten or drunk since the fast began, and when. It matters to the anaesthetist.
  6. Ask whether his regular medicines, or painkillers, can be taken with a sip of water. Don't give any by mouth without checking.
I don't have the hospital's own fasting protocol or his anaesthetic assessment, so the team's instruction is the final word.

Aspirations

Finding Sources
Finding Sources
Reading File
Reading File
Aspiration here means pulmonary aspiration. It is stomach contents (food, fluid or acid) passing into the windpipe and lungs, and it is why fasting before surgery matters.
Why it happens during anaesthesia
  • Anaesthesia relaxes the muscles and removes the cough and gag reflexes, so protection of the airway is lost. If the stomach is not empty, fluid can come up and be inhaled.
  • The result is aspiration pneumonitis, also called Mendelson syndrome. Acid damages the lung. It can cause breathlessness, low oxygen, wheeze and pneumonia, and it can be fatal. Mendelson first described it in 1946 in pregnant women under anaesthesia (Miller's Anesthesia, 10th ed.).
How common it is
  • Clinically significant aspiration is rare in healthy patients having general anaesthesia: about 1 in 3,000 to 1 in 6,000 anaesthetics. It rises to about 1 in 600 for emergency anaesthesia (Barash, Cullen, and Stoelting's Clinical Anesthesia, 9th ed.).
  • So fasting is a safety measure, and the risk is not high.
How it is prevented
  1. Fasting. The usual adult minimums are clear liquids 2 hours, a light meal 6 hours, and fried or fatty food 8 hours or more.
  2. Drugs. These are used only in higher-risk patients. They reduce stomach volume and acidity, such as antacids like sodium citrate, H2 blockers, and metoclopramide.
  3. Anaesthetic technique. The anaesthetist can choose a regional block, or a rapid-sequence induction if the stomach may not be empty.
Why his case may be treated more carefully
  • Pain, anxiety and opioid painkillers slow stomach emptying.
  • Injured patients who eat soon after trauma may still have a full stomach.
  • Surgery times often change, so a recent drink or snack could matter more.
  • Risk factors listed in Miller's include reflux disease, hiatal hernia, diabetes, obesity and pregnancy. Tell the anaesthetist if he has heartburn, acid reflux, diabetes or recent vomiting.
Practical advice
  • Keep to the nil-by-mouth instruction until the anaesthetist or nurse tells you otherwise.
  • Tell the team about anything he ate or drank since he began fasting, and when. They would rather know than guess.
  • Report nausea or vomiting straight away. If he vomits while drowsy, turn him onto his side, keeping the injured arm supported, and call the nurse.
  • A pre-anaesthetic check is normal. They will ask about his last meal and last drink, so give exact times.
I didn't run a PubMed check this time, because this is a basic safety explanation that doesn't depend on new trials. For his case the anaesthetist's plan is what counts.
This is a shared conversation. Sign in to Orris to start your own chat.