Closed Reduction of Distal Forearm Fractures by Pediatric Emergency Physicians

Department of Pediatrics, University of Tennessee Health Sciences Center, Memphis, USA.
Academic Emergency Medicine (Impact Factor: 2.01). 11/2010; 17(11):1169-74. DOI: 10.1111/j.1553-2712.2010.00917.x
Source: PubMed


The objective of this study was to determine if there exist differences in length of stay (LOS) in the emergency department (ED) and need for reintervention to restore alignment after distal forearm fracture reduction by pediatric emergency physicians (EPs) versus postgraduate year 3 or 4 orthopedic residents.
In a prospective trial at a busy urban pediatric ED, children with closed distal forearm fractures that met predefined criteria for manipulation were randomized to treatment by a postgraduate year 3 or 4 orthopedic resident or by a pediatric EP who had received focused training in forearm fracture reduction. Prereduction, postreduction, and follow-up radiographs were evaluated by an attending pediatric orthopedic surgeon who was unaware of the assigned group. The following outcomes were assessed: LOS during the initial ED encounter, adequacy of alignment immediately postreduction and at follow-up visits after discharge from the ED, the need for remanipulation, unscheduled ED visits, and radiographic healing at 6-8 weeks after injury.
A total of 103 children were randomized into the pediatric EP (52 patients, mean age 9.1 years) and orthopedic resident (51 patients, mean age 9.7 years) groups. Patients in the two groups were similar in age, involvement of the physes, degree of angulation, percentage of displacement, and need for procedural sedation. The mean LOS in the ED was 4.5 hours in the pediatric EP group versus 5.0 hours in the orthopedic resident group (difference in means -0.5 hours, 95% confidence interval [CI] = -1.26 to 0.37 hours). Remanipulation was required in 4 of 48 (8.3%) in the pediatric EP group versus 6 of 48 (12.5%) in the orthopedic resident group (odds ratio [OR] = 0.64; 95% CI = 0.16 to 2.67). Unscheduled ED visits for cast-related problems occurred in 6 of 51 (11.8%) in the pediatric EP group and 4 of 52 (7.7%) in the orthopedic resident group (OR = 1.59; 95% CI = 0.38 to 6.39). None of these patients with unscheduled ED visits developed compartment syndrome or required admission.
Length of stay in the ED and clinical outcomes after closed reduction of forearm fractures by trained pediatric EPs are comparable to those after closed reduction by orthopedic residents.

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Available from: Jeffrey R Sawyer, Sep 09, 2014
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    • "Forearm fractures are frequent in children (nearly 30%) [1] [2] [3]. Distal fractures of the metaphyseal radius are the most frequent, and several authors have shown that management in the ED is usually considered to be effective [4] [5], with successful reduction and a decrease in the number of hospitalizations and general anesthesia. On the other hand, the therapeutic approach to diaphyseal fractures is less clear. "
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    ABSTRACT: Diaphyseal forearm fractures are very common pediatric traumas. At present, distal radius metaphyseal fractures are often successfully treated with closed reduction by emergency physicians. However, the management of diaphyseal fractures remains controversial. The purpose of this study was to analyze the results of diaphyseal forearm fractures in the emergency department (ED) in children. In a prospective 2-year-study, all closed diaphyseal forearm fractures in patients under 15, with an angle of >15° and treated by closed reduction in the ED were included. Fractures with overlapping fragments were excluded. Reduction was performed by an emergency physician, with a standardized analgesic protocol (painkillers and nitrous oxide). Clinical tolerance was checked within the first 24hours, and the radiographic stability of reduction was assessed at days 8 and 15. Initial and final follow-up radiographs were analyzed. Elbow and wrist range of motion was assessed at the final follow-up. Sixty patients (41 boys and 19 girls) were included. Mean age was 5.2 years old (±3). At initial evaluation, the maximum angle was 30° (±11.3). After reduction, the maximum angle was significantly reduced (30° vs. 5°, P<0.001). Mean immobilization in a cast was 11.7 weeks (±2). There were no cast related complications in any of these children. There was no surgery for secondary displacement. Full range of motion was obtained in all patients at the final follow-up. The outcome of conservative treatment of closed diaphyseal forearm fractures, without overlapping fragments was excellent. However, reduction is usually performed in the operating room by orthopedic surgeons under general anesthesia and requires hospitalization, which is very expensive. The results of this study show that high quality care may be obtained in the ED by a trained and experienced team. These results are similar to those for distal metaphyseal fractures, which could extend the indications for reduction in the ED. Level IV. Retrospective study. Copyright © 2015. Published by Elsevier Masson SAS.
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    ABSTRACT: Procedural sedation has become widespread in emergency departments (ED) worldwide due to the ability to perform short turnaround noxious procedures beyond the confines of the operating theatre. We report one institution's experience with paediatric forearm fracture reduction and compare key time-based metrics for ED manipulation under procedural sedation (MUS), with traditional theatre-based manipulation under anaesthesia (MUA). All simple paediatric forearm fractures requiring manipulation before casting at Waikato hospital during the 2009 calendar year were studied. Time from presentation to fracture manipulation, procedure room occupancy, and hospital length of stay were recorded. Requirement for repeated intervention was additionally collated. Of 385 patients presenting with forearm fracture 108 underwent MUS and 66 MUA. Time to manipulation was shorter in the MUS group (58 plus or minus 38 minutes MUS vs. 558 plus or minus 368 minutes MUA; p<0.0001), as was hospital length of stay (139 plus or minus 70 minutes MUS vs 1452 plus or minus 544 minutes MUA; p<0.0001). No difference was observed in requirement for repeated intervention between groups (15% MUS vs 21% MUA; p=0.305). Manipulation of simple closed paediatric forearm fractures under procedural sedation was associated with lesser delay to reduction, and shorter hospital length of stay, compared with traditional manipulation under anaesthesia in the operating theatre.
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