Outcomes and Cost of Reduction of Overriding Pediatric Distal Radius Fractures

Abstract

Background: This study compared radiographic outcomes of pediatric patients undergoing closed reduction of 100% displaced distal radius fractures to a historical, published cohort treated with casting alone. We also examined the expense associated with sedated reduction. Methods: Single-center, retrospective cohort study examining radiographic outcomes following reduction of 100% translated distal radius fractures in 50 consecutive pediatric patients. Radiographic outcomes were compared with a historical cohort published by Crawford and colleagues. Charges associated with emergency department (ED) and clinic visits were compared between the reduction cohort and a comparison cohort of 13 patients with fractures not requiring reduction. Results: Forty-nine children (mean age 4.7 y) were included in this study. Duration of casting averaged 51 days and ED visit duration was 6.6±2.5 hours. Mean sagittal and coronal angulation at time of injury were 16.4 and 15.6 degrees, respectively, and were 13.2 and 9.4 degrees at the time of final follow-up. All fractures achieved radiographic union. Eighteen patients underwent a total of 21 unexpected cast changes. No patients required repeat sedation or surgical management. Angulation after casting was significantly better in the reduction cohort compared with the casting-only cohort initially, however, at final follow-up, both coronal and sagittal angulation were significantly worse in the reduction cohort compared with the casting-only cohort (coronal angulation 8.59 vs. 0.75, P<0.0001; sagittal angulation 13.49 vs. 2.2, P<0.0001). Charge analysis compared 46 patients in the reduction cohort to 13 patients with unreduced fractures from the same institution during the same time period. Mean clinic charges were similar ($1957 vs. $2240, P=0.3008). ED charges were higher in the reduction cohort compared with the nonreduction cohort ($7331 vs. $3501, P<0.001), resulting in higher total charges in the reduction cohort ($9245.04 vs. $5740.99, P<0.001). Conclusions: While closed reduction of 100% translated distal radius fractures in the pediatric population improves angulation initially, casting alone may provide similar or better radiographic outcomes, expedited care, reduced patient exposure to the risks of procedural sedation, and avoidance of ED charges associated with procedural sedation. Level of Evidence: Level III—therapeutic.

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“…23 Savings with nonsurgical management are compounded if closed reduction and immobilization can be performed in the emergency department 24 rather than in the clinic, although conscious sedation costs can be significant. 25 Although no specific data regarding the cost of emergency department management specifically for SCH fractures is available, we do know that the costs in the emergency department vary greatly by region and by type of sedation performed, 26,27 and PHIS data demonstrates that surgical treatment of pediatric distal radius fractures results in hospital costs over 500% of nonsurgical treatment. 26 Future studies directly comparing the costs of operative fixation versus sedated reduction and casting in SCH fractures would inform this discussion dramatically.…”

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“…In addition, patients who had closed reduction spent a mean time of 6.6 hours in the emergency department and had more than double the emergency department charges ($7,330) compared with patients treated with in situ casting ($3,500). Furthermore, 36 (72%) of 50 patients in the reduction group had unacceptable alignment at some point in their follow-up requiring additional manipulation or cast modification 56 . These results beg the question of why a patient should be subjected to conversion of a stable fracture to an unstable fracture, with its inherent costs and complications, if final outcomes are similar.…”

“…There remains unease about how best to treat patients <10 years of age with distal radial fractures that are 100% displaced and overriding, despite evidence from 2012 in favor of in situ immobilization 55 . A recent study compared a reduction and casting cohort of 50 patients 56 with a historic in situ casting cohort of 51 patients 55 . At the final follow-up, there was significantly worse angulation in the reduction group in both the sagittal plane (13.49° compared with 2.2°) and the coronal plane (8.59° compared with 0.75°).…”

Outcomes and Cost of Reduction of Overriding Pediatric Distal Radius Fractures

“…We read with interest the recent publication by Bradley and colleagues. 1 In 2012 Crawford et al 2 reported that overriding extra-physeal distal radius fractures with or without ulnar fracture can be successfully treated with a moulded below elbow cast in children 10 years of age and younger. All treatments were provided by a single pediatric orthopaedic surgeon who applied the casts within 72 hours of injury, only correcting angulation, with the majority of patients having had at least one further cast change by the same surgeon.…”

“…Crawford et al's 2 technique is more than just "casting alone" as it was simplified by Bradley et al 1 As Bradley et al 1 concluded that casting alone of off-ended distal radius fractures may be a preferable option in accordance with Crawford et al's 2 practice, we would like to ask the authors if their unit has stopped reducing the overriding of off ended distal radius fractures, if all patients are now manged with a moulded cast applied by a pediatric orthopaedic surgeon at the time of the first clinic visit to correct angulation, if they have stopped using above elbow casts and if they have shortened their casting period from a mean of 51 days to Crawford et al's 2 mean of 42 days?…”