Hemorrhage of the forearm

Temporary arrest of bleeding by flexion

The positional method of stopping bleeding is based on the compression of major vessels during maximal flexion of the limb. The main condition for the effectiveness of this maneuver is reliable fixation of the limb in this position.

• Bleeding from the vessels of the forearm or hand: the arm must be flexed as much as possible at the elbow joint and rigidly fixed.
• Injuries of other locations: by comparison, in case of bleeding from the leg or foot, the leg is fixed in the maximally flexed knee joint, and in high injuries of the femoral artery when tourniquet application is technically unavailable, the thigh is fixed with simultaneous maximum flexion at the hip and knee joints.

Clinical anatomy of the forearm

Surgical treatment of injuries and arrest of massive bleeding require a precise understanding of the anatomy of the forearm bone framework. The framework consists of two bones connected by the interosseous membrane (membrana interossea) and ligaments of the radioulnar joints.

Ulna (ulna) It is located medially and has a straight shape. It participates in the formation of the humeroulnar joint, as well as the distal and proximal radioulnar joints. In the biomechanics of the upper limb, it plays the role of a fixed axis of rotation around which rotational movements of the forearm are performed.

Radius (radius) It has a characteristic outward curve, which is a critically important condition for the normal execution of rotational movements. The articular apparatus includes:

• Proximal part: forms the humeroradial joint by articulating with the head of the humeral condyle.
• Distal part: forms the radiocarpal joint, articulating with the proximal row of carpal bones.
• Like the ulna, it participates in the proximal and distal radioulnar joints.

Blood-saving technologies in surgery

During the surgical treatment of forearm and arm injuries (e.g., osteosynthesis or arthroplasty), strategies are applied to minimize the need for donor blood.

Tranexamic acid The drug solution is administered intravenously in the perioperative period to adult patients at risk of bleeding. The use of tranexamic acid has been proven to reduce blood loss volume and prevent a sharp drop in hemoglobin levels after surgery on the proximal humerus.

Iron preparations Used in the postoperative period in adults, but have an obligatory condition: the presence of laboratory-confirmed iron deficiency anemia. Intravenous administration (specifically, ferric carboxymaltose) serves as an effective alternative to blood transfusion. Clinical effects of iron preparations:

• Reduction in the proportion of patients requiring blood transfusion.
• Decrease in the volume of transfused packed red blood cells.
• Reduction in the rate of infectious complications.
• Please note: iron therapy does not affect mortality rates.

Associated injuries and thromboprophylaxis

When a forearm bone fracture is combined with a dislocation, damage to the capsule-ligamentous apparatus always occurs. Emergency reduction of the dislocation is required. If the elbow joint remains unstable after osteosynthesis, the ligaments are surgically repaired. Short-term immobilization before surgery is permitted only if the joint is markedly unstable and emergency surgery is currently impossible.

Venous thromboembolism (VTE) prophylaxis Extensive soft tissue injuries and upper limb fractures require pharmacological thromboprophylaxis if additional risk factors are present (age, diabetes mellitus, estrogen use, prothrombin G20210A mutation).

• Regimen: the attending physician prescribes low-molecular-weight heparins (LMWH) for 7–10 days perioperatively or until motor activity is restored.
• Children: risk assessment is performed within the first 24 hours. There are no validated scales for children, and decisions are made individually. In case of high risk, the appointment of LMWH or unfractionated heparin is considered, although the use of LMWH in children in the Russian Federation faces regulatory restrictions.

The prescription of any off-label drugs in the presence of contraindications is permitted only by decision of the medical commission.

Class and exam questions

What else to study on this topic

• Surgical tactics for forearm dislocations and elbow instability
• Regimens and dosages for prescribing low-molecular-weight heparins (LMWHs)
• Legal aspects of off-label drug use in children
• Biomechanics of the radiocarpal and humeroradial joints
• Assessment of VTE risk factors in metabolic disorders

Other topics in the "Additional Topics" section

Prepared by WhiteCoat Pro faculty in accordance with the medical school curriculum. For educational purposes only.