Resource Utilization for Patients With Distal Radius Fractures in a Pediatric Emergency Department

Abstract

IMPORTANCE Improvement of clinician understanding of acceptable deformity in pediatric distal radius fractures is needed. OBJECTIVE To assess how often children younger than 10 years undergo a potentially unnecessary closed reduction using procedural sedation in the emergency department for distal radial metaphyseal fracture and the associated cost implications for these reduction procedures. DESIGN, SETTING, AND PARTICIPANTS This retrospective cross-sectional study included 258 consecutive children younger than 10 years who presented to a single, level I, pediatric emergency department and who had a distal radius fracture with or without ulna involvement between January 1, 2016, and December 31, 2017. Reductions were deemed to be potentially unnecessary if the coronal and sagittal plane angulation of the radius bone measured less than 20°and shortening measured less than 1 cm on initial injury radiographs. Use of procedural sedation or transfer status to another facility was noted if present. Statistical analysis was performed from April 2019 to June 2019. MAIN OUTCOMES AND MEASURES Potentially unnecessary reduction was the primary outcome. Radiographic findings were measured to determine reduction necessity. Additional variables measured were age, sex, time in the emergency department, transfer status, required reduction procedure, use of sedation, and cost associated with care. RESULTS Of the 258 participants studied, 156 (60%) were male, with a mean (SD) age of 6.7 (2.3) years. Among 142 patients (55%) who underwent closed reduction with procedural sedation in the emergency department, 38 (27%) procedures were determined to be potentially unnecessary. Review of Common Procedural Terminology charges revealed an approximately $7000 difference between the stated cost of a reduction procedure in the emergency department vs a cast application in an outpatient orthopedic clinic for distal radial metaphyseal fractures. The mean (SD) maximal angulation in either plane for fractures that underwent appropriate reduction was 30.6°(10.3°) compared with 13.9°(4.5°) for those unnecessarily reduced (P < .001). Patients who were transfers from other facilities were more than twice as likely to undergo a potentially unnecessary reduction (odds ratio, 2.3; 95% CI, 1.1-5.0; P = .03). CONCLUSIONS AND RELEVANCE The findings suggest that improved awareness of these acceptable deformities in young children may be associated with limiting the number of children requiring reduction with sedation, improving emergency department efficiency, and substantially reducing health care costs.

Management of isolated distal end of radius fracture in pediatric age group: An observational study

“…11 The authors found that 172 (56%) of the 305 children were boys and remaining 133 (44%) were girls. Similar male preponderance in the incidence of distal radius fracture was also reported by the authors such as Orland KJ et al, 12 and Syurahbil AH et al 13 In our study the mean age of affected cases in Boys and Girls was found to be 13.09 +/-2.93 years and 12.5+/-3.64 years respectively. Sengab A et al, performed a meta-analysis of 3 randomized controlled trials and 3 cohort studies, analyzing 197 patients treated with cast immobilization alone and 185 with additional K-wire fixation.…”

Displaced Distal Radius Fractures in Children: To Reduce or Not to Reduce? To Pin or Not to Pin?

“…13,14 The cost of reduction is also far greater, ranging from 50% to 700% more than non-reduction treatment. 5,15 Figure 1 shows the radiographs of a 6-year-old male who sustained a distal radius and ulna fracture after a fall at a playground. Radiographs at one-week post-injury were significant for 30° of apex volar angulation and 25° of radial angulation (Figure 1a).…”

“…Patients undergoing ED reduction spend two hours longer in the ED than those undergoing nonreduction treatment. 5,15 Crawford et al found that ED reduction and casting cost $3,819 more than an office visit application of a cast ($4,846 vs. $1,027). 4 Orland et al performed a cross-sectional study at a single tertiary pediatric emergency room in the USA and found that the cost difference between those reduced and not reduced was estimated at approximately $7,000 ($8,077 vs. $1,027).…”

“…These concerns lead to procedural sedation for many of the estimated 280,000 distal radius fractures seen each year in children less than 10 years of age in the U.S. 5 One study of consecutive patients under age 10 who were seen in an ED for a distal radius fracture showed that 55% (142/258) underwent sedated reduction and immobilization. 5 Abstract: Displaced distal radius fractures in children are routinely treated with closed reduction under sedation, which adds risk and cost. Yet some metaphyseal fractures, especially in young children (under age 10), have the capacity to remodel some degrees of displacement without reduction.…”

Outcomes and Cost of Reduction of Overriding Pediatric Distal Radius Fractures

“…[8][9][10][11][12][13] It has been suggested that it is unnecessary to perform reduction maneuvers in pediatric patients with distal radius factures because of their marked remodeling potential, 2,3,7,[14][15][16][17][18][19] and furthermore, performance of closed reduction results in increased cost, patient risk, hospital time, and provider time. 14,20,21 In addition, closed reduction of pediatric distal radius fractures commonly requires sedation to minimize patient pain and to allow for more anatomic reduction, which subjects patients to risks of sedation including respiratory depression, hypoxia, hypotension, nausea, and aspiration. [21][22][23][24] The purpose of this study was to determine what percentage of 100% displaced pediatric distal radius fractures that undergo closed reduction develop unacceptable angulation, rates of failure requiring repeat intervention including second sedation procedures, cast changes, and extra clinic visits, and the added expense, if any, associated with sedated emergency department (ED) reduction.…”